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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176800009
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:42:06 AM

Document Has Been Signed on 05/02/2024 11:42 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KONOCTI INSTRUCTIONAL SERVICES - CLEARLAKEFACILITY NUMBER:
176800009
ADMINISTRATOR/
DIRECTOR:		MEGAN KAPITANFACILITY TYPE:
775
ADDRESS:14560A LAKESHORETELEPHONE:
(707) 994-1560
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 79CENSUS: 22DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Matt Bottorff, Interim Program DirectorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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At 9:00 AM Licensing Program Analysts (LPA’s) Shannan Hansen and Jacqueline Macias arrived unannounced to this Licensed Day Program to conduct an Annual Required inspection to this facility and met with Matthew Bottorff, Interim Program Director.

LPA’s and Interim Program Director toured the facility and grounds, which was found to be clean and in good repair. This Day Program operates Monday-Friday. There were 22 clients and 15 staff present at the time of this inspection. LPA's 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, as they were during inspection. Clients bring their own lunches. Toxins are centrally stored in a locked closet in the kitchenette area & janitors closet. 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 in Interim Program Directors Office. Fire system has a pull station, fire extinguishers were serviced 9/15/2023. Smoke detectors & Carbon Monoxide detectors tested and in working order.

A review of five clients & five staff records was conducted. LPA’s reviewed clients files at 10:30 AM and learned that 5 of 5 clients records were found to be current, including: admission agreement; personal rights; health screening & care plan. Medication review conducted, found to be through and up to date.

LPA’s reviewed a sample of staff records at 10:00 AM and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Staff records reviewed were current including required training's & health screening. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed.
Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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: 05/02/2024
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LPA’s reviewed Licensing Information System (LIS) with Interim Program Director who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills are conducted monthly practicing different drills with the last one being conducted on 3/11/2024.


No deficiencies were found in the areas inspected, No citations issued during today's visit.


LPA Hansen is requesting updated documents to be submitted to SRRO by 5/24/2024:

LIC308- Designation of Responsibility (if changes)
LIC400 Affadavit Regarding Client Resources
LIC402 Surety Bond
LIC500- Personnel Report
LIC610D- Disaster Plan (if changes)
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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