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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 233009332
Report Date: 08/11/2022
Date Signed: 09/07/2022 01:12:45 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2022 and conducted by Evaluator Mary Trinh
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20220606121607
FACILITY NAME:HENDRICKS, KRISTINE FCCHFACILITY NUMBER:
233009332
ADMINISTRATOR:HENDRICKS, KRISTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 962-3003
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY:14CENSUS: 3DATE:
08/11/2022
UNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Kristine HendricksTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee does not reside in the home.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, (LPA) Mary Trinh met with Licensee (L1), Kristine Hendricks to deliver complaint finding. It has been alleged that Licensee does not reside in the home.
On 06/13/2022 at 3:45 pm, LPA Trinh interviewed L1 who stated that she resides at her FCCH. LPA Trinh requested copy of Children's Roster, and documentation which shows the Licensee's mailing address. LPA Trinh interviewed Parents (P1, P2, P3) who stated that License does live in her FCCH. On 08/11/2022 LPA Trinh interviewed Child 1 and Child 2 (C1, C2) who stated they live in the FCCH.
Continued..
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Mary TrinhTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 01-CC-20220606121607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HENDRICKS, KRISTINE FCCH
FACILITY NUMBER: 233009332
VISIT DATE: 08/11/2022
NARRATIVE
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This agency has investigated the complaint alleging Licensee does not reside in the home. We have found that the allegations are Unsubstantiated. Based on the information gathered during this investigation, there is insufficient information to prove or disprove the allegation. There were no Title 22 deficiencies cited during today's inspection. This report was reviewed and discussed with Licensee. Appeal Rights were provided.
Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Mary TrinhTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2