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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001884
Report Date: 02/04/2025
Date Signed: 02/05/2025 11:38:04 AM

Document Has Been Signed on 02/05/2025 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CRP RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KOINONIA CRISIS RESOLUTION CENTER - ANTELOPEFACILITY NUMBER:
347001884
ADMINISTRATOR/
DIRECTOR:		KATIE DANNERFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: DATE:
02/04/2025
TYPE OF VISIT:Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Katie Danner, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Mary Shelton made an unannounced annual inspection on 2/4/2025 at 9:30 AM and met with Katie Danner, Administrator, who assisted with the inspection. LPA did advise the agency that the inspection is being completed with the use of the CARE Tool.

LPA Shelton conducted a walk-through of the facility inside and out with Toma Paskal, Youth Counselor. There was one client present during the inspection. LPA observed three bedrooms with two beds in each room. Two bathrooms with hot water, soap and paper towels for clients in care.

LPAS Shelton inspected and/or reviewed the following:

· Postings of facility license and Personal Rights Poster were appropriately posted.
· Disinfectants/Cleaning solutions were inaccessible and locked as required.
· Refrigerator Temperature was in compliance.
· Nonperishable Foods for one week and fresh perishable for foods two days minimum were present.
· Menu was present and posted.
· LPA observed a working telephone on the premises.
· Carbon monoxide detectors and Smoke Detectors were present.
· First Aid Kit was present and fully stocked as required.
· Common Room (living room) was available as was a therapy room for privacy.
· Dining area with enough seating for clients in care was present and in good condition.
· Medication was centrally stored, locked/inaccessible. Centrally stored medication and log reviewed.
Cont.
SUPERVISORS NAME: Jodean Hall
LICENSING EVALUATOR NAME: Mary Shelton
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CRP RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KOINONIA CRISIS RESOLUTION CENTER - ANTELOPE
FACILITY NUMBER: 347001884
VISIT DATE: 02/04/2025
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·LPA reviewed (3) three staff files and (1) client file as well as conducted interviews with three (3) staff and (1) client.
· LPA observed Locked Facilities included a shed with lawn equipment and other items.
· Board Minutes were reviewed.
· Disaster Preparedness was updated and available for review, quarterly drills are completed and logged in a binder and there are disaster preparedness supplies available and verified by LPA.
· Staff training was in compliance.
· Criminal record clearances were verified by LPA and in compliance.
· Staff files reviewed had First Aid Certificates and CPR cards with a valid date as required.
· Certified Administrators certificate was valid and current.
· Staff job titles/qualifications were verified along with the required 24 Hours of initial training.
· Facility is free of vermin.
· Disinfectants/Cleaning solutions are inaccessible and stored in the staff bathroom.

The following items were reviewed for compliance in the regional office prior to the facility inspection:
Administrator Certificate for Katie Danner is current and verified. No Fees are due at this time.
LPA requested the following document LIC 500 as part of the annual review:

No citations were issued to the agency at the conclusion of the inspection.

SUPERVISORS NAME: Jodean Hall
LICENSING EVALUATOR NAME: Mary Shelton
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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