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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176800009
Report Date: 03/27/2023
Date Signed: 03/27/2023 12:10:09 PM

Document Has Been Signed on 03/27/2023 12:10 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: 25DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Megan Dorman, Program Director & Matt Bottorff, Site Coordinator.TIME COMPLETED:
12:15 PM
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At 9:00 AM Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to this Licensed Day Program to conduct an Annual Required inspection to this facility and met with Megan Dorman, Program Director and Matt Bottorff, Site Coordinator.

LPA and staff toured the facility and grounds, which was found to be clean and in good repair. This Day Program operates Monday-Friday. There were 3 clients and 6 staff present at the time of this inspection. 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. Day Program operates an Art & Sewing Gallery that on occasion sell their completed items at the front of the building. Clients bring their own lunches. Toxins are centrally stored in a locked closet in the kitchenette area. Water temperature measured within regulation between 105 and 120 degrees F. at faucets accessible to clients. Client money is handled by facility and kept individually in locked drawers in the office with ledgers and receipts. There is a locked cabinet for medications to be stored but at this time there are no participants taking medications. Fire system has a pull station, fire extinguishers were serviced 9/19/2022. Carbon Monoxide detectors tested and in working order. Disaster Drills are conducted monthly.

LPA reviewed 3 staff records and 3 client records which were found to be thorough and contained the required information.

LPA Hansen is requesting updated documents to be submitted to SRRO by 4/14/2023:
LIC308- Designation of Responsibility
LIC400 Affadavit Regarding Client Resources
LIC500- Personnel Report
LIC610D- Disaster Plan

No deficiencies were found in the areas inspected, No citations issued during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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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