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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176800009
Report Date: 03/08/2022
Date Signed: 03/08/2022 02:02:48 PM

Document Has Been Signed on 03/08/2022 02:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KONOCTI INSTRUCTIONAL SERVICES - CLEARLAKEFACILITY NUMBER:
176800009
ADMINISTRATOR:MEGAN DORMANFACILITY TYPE:
775
ADDRESS:14560A LAKESHORETELEPHONE:
(707) 994-1560
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 79CENSUS: 48DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Megan Dorman - Administrator & Athena Dore Site CoordinatorTIME COMPLETED:
02:03 PM
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At Approximately 12:15 PM License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year Infection Control Inspection of the facility. LPA was welcomed by Program Director Megan Dorman. There are 48 clients enrolled in the program, with approximately 11-15 clients at the facility daily.

LPA arrived at the facility and had temperature checked and health questions asked. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA met with Site Coordinator Athena Dore and toured the facility. The entrance area has a small table with hand sanitizer, thermometer and other items designated for Clients, Staff and visitors before coming into the facility. Facility has PPE supplies stored in the supply closet. There were hand washing stations and hand sanitizer located throughout the building.

This Day Program operates Monday -Friday. There were 10 Clients and 15 Staff present at the time of this inspection. The facility consists of offices, three large activity rooms, a quiet room, changing area, a kitchen (under construction), and five bathrooms. LPA observed the facility was a comfortable temperature and found all exits and walkways to be unobstructed. The facility grounds were also kept clean and without hazards. Clients bring lunches. Snacks are available for clients. There is a cooking class offered to clients once a week. Clients activities include making jewelry, sewing projects, cooking and art classes, book reading club, science club, book reading club, and landscaping work.
Toxins are centrally stored in a locked closet in the staff area. Client money is not handled by facility. Facility keeps client's medications centrally stored and locked in a cabinet in a staff office when they do have clients who take medication.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KONOCTI INSTRUCTIONAL SERVICES - CLEARLAKE
FACILITY NUMBER: 176800009
VISIT DATE: 03/08/2022
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Infection Controle:

Facility has submitted a mitigation program plan that was approved on 05/11/2021. All staff, clients, & visitors check in with the electronic temperature log and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed throughout facility. Facility has PPE supply stored in closet in staff office with emergency supplies. Staff had all PPE training required on file and are working on getting N95 Fit Tested.



Disaster Drills are conducted monthly with the last being 02/28/2022.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1st Aid certification for staff.

Lake County Fire Protection District, Fire Marshall Chris Smith arrived at facility when LPA was conducting inspection. Fire Marshall also did inspection of renovation in room and provided signed off fire safety inspection.

There were no deficiencies found in the areas inspected.



No citations issued.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/31/2022 to RPRO:


LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Disaster Plan
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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