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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176800042
Report Date: 05/17/2022
Date Signed: 05/17/2022 11:52:25 AM

Document Has Been Signed on 05/17/2022 11:52 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 - LAKEPORTFACILITY NUMBER:
176800042
ADMINISTRATOR:VICKI COLEFACILITY TYPE:
775
ADDRESS:870 ELEVENTH STREETTELEPHONE:
7072637714
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY: 40CENSUS: 22DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Assistant Executive Director Megan KapitanTIME COMPLETED:
11:52 AM
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At Approximately 9:45 AM License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year Infection Control Inspection of the facility. LPA was welcomed by Secretary Carole Becker & Lead Skills Instructor Katie Johnson that called Assistant Executive Director Megan Kapitan who arrived shortly after. There are 22 clients enrolled in the program, with approximately 4 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 toured the facility with Staff Katie Johnson & Carole Becker. 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.

The facility consists of 3 offices, two large activity rooms, a kitchen, and 4 bathrooms. The facility grounds were also kept clean and without hazards. There is a cooking class offered to clients once a week. Clients activities include, art classes, gardening, and going to the park. Toxins are stored in locked cabinets & closets.

Infection Controle:

Facility has submitted a mitigation program plan that was approved on 01/27/2021. All staff, clients, & visitors check in and have temperature checked and logged 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 upstairs closet with emergency supplies. Staff had all PPE training required on file and have been N95 Fit Tested.



Disaster Drills are conducted monthly with the last being 4/29/2022.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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 - LAKEPORT
FACILITY NUMBER: 176800042
VISIT DATE: 05/17/2022
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LPA reviewed Licensing Information System (LIS) with Asst. Ex. Director who informed the Director and email needs to be changed. LPA advised to submit LIC200 with correct 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.

Adult Day Program has been given 2 Technical Assistance: 82088(e)(1) has been experiencing hot water heater problems for approximately a month, water was 93.7 degrees F. at end of visit after giving time to heat up. 82019(f); to have staff background cleared & associated or have a transfer.

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 5/31/2022 to SRRO:



LIC200 Current LIS information
LIC500 Personnel Report
LIC308 Designation of Responsibility

LIC400 Affidavit Regarding Client Cash Resources


LIC 401 Surety Bond
LIC 610 Emergency Disaster Plan
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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