233009332-6-1-2021-01-CC-AHON-C3LSRK-20210602140626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 233009332
Report Date: 05/28/2021
Date Signed: 06/01/2021 07:15:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2021 and conducted by Evaluator Leticia Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 01-CC-20210301120624

FACILITY NAME:	HENDRICKS, KRISTINE FCCH		FACILITY NUMBER:	233009332
ADMINISTRATOR:	HENDRICKS, KRISTINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 962-3003
CITY:	FORT BRAGG	STATE: CA	ZIP CODE:	95437
CAPACITY:	14	CENSUS: 0	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Kristine Hendricks		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Licensee does not reside in the home.

Licensee operates beyond the terms and conditions of the license.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Leticia Rosales-Meza conducted a subsequent complaint tele-investigation video conference with Kristine Hendricks, Licensee for the purpose of delivering complaint investigation findings. Due to COVID-19, the Department has suspended field operations, and Licensee has agreed to attend a FaceTime video
tele-inspection in place of an in-person, site visit. It has been alleged that Licensee does not reside in the home, specifically that Licensee does not live there at all but comes back for work. It has been alleged that Licensee operates beyond the terms and conditions of the license, specifically that Licensee had a full time worker and had been watching 12-16 children.

During the initial investigation an interview was conducted with Licensee on 03/03/21 at 04:30 PM. The Licensee denied the allegations.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Leticia Rosales	TELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 01-CC-20210301120624

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: HENDRICKS, KRISTINE FCCH	FACILITY NUMBER: 233009332
	VISIT DATE: 05/28/2021

NARRATIVE

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Licensee stated that she lives in the home with her two sons, and that she definitely is not watching twelve to sixteen children, nor did my assistant. Licensee stated that she is licensed for fourteen children, but she only has eight children enrolled at the moment and they all don't come the same day. Licensee stated she only has four to six children the most, a day. Licensee stated she does not have an assistant at the moment, since October 2020 was the last time she had an assistant.

An interview was conducted with Adult 1 (A1) on 5/19/21 at 2:33 PM. An interview was conducted with Adult 2 (A2) on 5/21/21 at 11:14 AM.

An interview was conducted with Parent 1 (P1) on 5/21/21 at 12:50 PM. An interview was conducted with Parent 2 (P2) on 5/21/21 at 12:50 PM. An interview was conducted with Parent 5 (P5) on 5/25/21 at 4:35 PM. An interview was conducted with Parent 6 (P6) on 5/27/21 at 5:31 PM. Interviews were conducted with Child 1 (C1) and Child 2 (C2) on 05/27/21 starting at 4:43 PM.

During the virtual tele-inspections LPA observed the living room where Licensee stated they do circle time. LPA observed plenty of toys and materials to do art project, plenty of food in the refrigerator, and in the cabinets. LPA observed dog food in a bucket with a snap lid in the kitchen, Licensee's bedroom with personal belongings, as well in the bathrooms. LPA observed Licensee's son's rooms with all of their personal belongs.

Based on interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, therefore the allegations are Unsubstantiated.

LS’s signature was not recorded on this Complaint Investigation Report (CIR), however, this report was reviewed and discussed with LS, LS was provided with a copy of this CIR; and Appeal Rights, LS’s signature will be on file. All licensing reports are public information and must be made available upon request for at least three years.

There were no Title 22 deficiencies cited during today's video inspection.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Leticia Rosales	TELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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