176800009-4-27-2026-21-AS-JFLO-DTJUGL-20260427153431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 176800009
Report Date: 04/27/2026
Date Signed: 04/27/2026 03:34:44 PM

Document Has Been Signed on 04/27/2026 03:34 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	KONOCTI INSTRUCTIONAL SERVICES - CLEARLAKE		FACILITY NUMBER:	176800009
ADMINISTRATOR/ DIRECTOR:	MEGAN KAPITAN		FACILITY TYPE:	775
ADDRESS:	14560A LAKESHORE		TELEPHONE:	(707) 994-1560
CITY:	CLEARLAKE	STATE: CA	ZIP CODE:	95422
CAPACITY: 79		CENSUS: 23	DATE:	04/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Megan Kapitan, Associate Executive Director		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 1:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Required - 1 Year inspection and met with Megan Kapitan, Associate Executive Director (AED). Facility provides in-person services, Monday through Friday from 9:00 AM - 3:00 PM. Facility offers transportation services to and from their day program. Facility is vendored with Redwood Coast Regional Center (RCRC) and all the clients have a service coordinator. At approximately 1:45 PM LPA initiated tour of the facility with AED and observed the following: facility was a comfortable temperature and the required signage was posted. Exits were observed unobstructed and chemicals and other items which could pose a risk to clients in care were observed inaccessible to clients in care. Hygiene and paper products were available to clients. Water temperatures in facility bathrooms tested within the allowable range of 105-120 degrees Fahrenheit per Title 22 regulations. LPA observed a first aid kits, PPE, emergency supplies, and incontinent care products. Fire extinguishers were observed fully charged and last inspected 09/2025. Smoke and carbon monoxide detectors were tested and operational during inspection. Facility conducts monthly emergency disaster drills with the last drill conducted 04/2026 LPA reviewed facility's emergency disaster plan which last updated 03/2025. Facility's telephone was tested and operational during inspection. LPA observed clients engaged in crafting activities and playing games during inspection. Facility focuses on the arts, music, gardening, and cooking and selling food. The clients have a store front in the facility where they sell their artwork (tie die clothing, jewelry, fabric bags, paintings, and more). The clients also have a cafe where they make and sell coffee shop items. The proceeds go to the clients. Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KONOCTI INSTRUCTIONAL SERVICES - CLEARLAKE	FACILITY NUMBER: 176800009
	VISIT DATE: 04/27/2026

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continued from LIC809...

Facility also has computers for client use. Facility director states that clients participate in scheduled outings daily. Medications and P&I cash resources were both observed stored and maintained within regulation.

At approximately 2:15 PM, LPA initiated file review of five (5) client files and five (5) staff files. All client files reviewed had all the required documentation per regulation. All staff files reviewed contained all the required documents, including proof of current first aid and CPR training for staff.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC610D - Emergency Disaster Plan (updated)

No deficiencies cited during today's inspection.

Exit interview conducted with AED, whose signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

LIC809 (FAS) - (06/04)

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