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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176800042
Report Date: 05/01/2023
Date Signed: 05/01/2023 11:24:21 AM

Document Has Been Signed on 05/01/2023 11:24 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:MEGAN KAPITANFACILITY TYPE:
775
ADDRESS:870 ELEVENTH STREETTELEPHONE:
(707) 263-7714
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY: 40CENSUS: 15DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ashley Barrett - Program DirectorTIME COMPLETED:
11:40 AM
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At approximately 9:15 AM, Licensing Program Analyst (LPA) Shannan Hansen conducted an unannounced Annual Required inspection to this facility and met with Program Director, Ashley Barrett. At approximately 9:20 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. Hot water at kitchen and client restroom faucets was within regulation between 105 and 120 degrees F. Bathroom supplies were sufficient. Toxins were safely stored under the kitchen sink. There were currently no Medications at facility but there is a secure space to store. Fire extinguishers are charged and current, last inspection 8/4/2022. Carbon monoxide detectors were tested and found to be in working order. Smoke detectors are hardwired and are tested every 3 years, with the last inspection in June 2021.
At approximately 10:15 AM, LPA reviewed 4 staff and 4 client records. Records were well organized and contained the required documentation. First aid and CPR certification was current. P & I monies were documented, secure and not commingled. Client files were found to be thorough and contain current client care assessments and individualized Service Plans.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/15/2023:

LIC400 Affidavit Regarding Client/Resident Cash Resources
LIC 401- Surety Bond
LIC 500-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: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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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