347001884-3-4-2021-23-CR-JGRE-BYUP7A-20210306100332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001884
Report Date: 03/04/2021
Date Signed: 03/04/2021 04:46:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/24/2020 and conducted by Evaluator Robin Sullivan

PUBLIC

COMPLAINT CONTROL NUMBER: 23-CR-20201124150707

FACILITY NAME:	KOINONIA CRISIS RESOLUTION CENTER - ANTELOPE		FACILITY NUMBER:	347001884
ADMINISTRATOR:	BILL RYLAND		FACILITY TYPE:	730
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	6	CENSUS:	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Katie Danner, Administrative Assistant		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff are not wearing mask in the facility.

INVESTIGATION FINDINGS:

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On 3/4/2021, Licensing Program Analyst (LPA) Robin Sullivan conducted an unannounced tele-conference call, due to COVID19, to deliver findings for a complaint investigation and spoke with Katie Danner, Facility Administrative Assistant. LPA Sullivan is delivering the findings for the investigation conducted by LPA Michelle Goodman.
During the investigation a tele-inspection was conducted at the Group Home on December 2, 2020 at 10:37 AM. LPA Goodman received copies of the following documents via email: CRC Antelope Duty Roster-December, Policy & Procedures for California Face Covering Requirement, Covid-19 Higher Risk Activity, Infection Control Procedures, Visitation Restrictions, Physical Distancing Protocol, Covid-19 Exposure Report & Protocol. Interviews were conducted on the following dates: Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4) were interviewed on 12/1/20. Staff 5 (S5), Staff 6 (S6) and Staff 7 (S7) were interviewed on 12/15/20 and Staff 8 was interviewed on 12/22/20. (see LIC 811 Confidential Names List dated 2/xx/21)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jodean Greene	TELEPHONE: (916) 263-4711
LICENSING EVALUATOR NAME: Robin Sullivan	TELEPHONE: (916) 201-8328
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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 23-CR-20201124150707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

FACILITY NAME: KOINONIA CRISIS RESOLUTION CENTER - ANTELOPE	FACILITY NUMBER: 347001884
	VISIT DATE: 03/04/2021

NARRATIVE

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The investigation revealed the following:
According to Koinonia Family Services California Face Covering Requirement policies and procedures dated 8-24-20 indicates that face coverings are not required during counseling or crisis intervention due to the crucial need to rely on facial expressions or when able to maintain physical distancing from others. Interviews conducted with S4, S7, S8 indicted that mask are to be worn when prepping food, administering medication and when social distancing cannot be obtained in the house. S2 indicated that they can wear mask if they prefer and some will wear them when walking in the hallway. S3 indicated that mask are required for prepping food and administering medication but there is lead way when speaking to youth. S6 has indicated that face shields are available for employees to use opposed to face mask. California Department of Social Services Provider Information Notice 20-19 CRP states in part “Staff working at congregate care facilities are mandated to wear face coverings while at work, under the following circumstances:…Working in or walking through common areas, such as hallways, stairways, elevators and parking facilities; In any room or enclosed area where other people…are present when unable to physically distance”. S4, S5, S7 and S8 indicated during the interview that the facility is large enough to maintain social distancing inside the house. S8 also indicated that they can keep distance in the hallway because it’s a big facility.
Based on the documents obtained and the interviews conducted the allegation that staff are not wearing masks in the facility is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
An exit interview was conducted and a copy of this report, appeal rights, and the LIC811 will be emailed to Katie Danner with a read receipt attached.

SUPERVISOR'S NAME: Jodean Greene	TELEPHONE: (916) 263-4711
LICENSING EVALUATOR NAME: Robin Sullivan	TELEPHONE: (916) 201-8328
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

LIC9099 (FAS) - (06/04)

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