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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602858
Report Date: 06/08/2023
Date Signed: 06/08/2023 01:31:41 PM

Document Has Been Signed on 06/08/2023 01:31 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KOKUMAH EVERYDAY GRACE ONE INCORPORATIONFACILITY NUMBER:
198602858
ADMINISTRATOR:JOHN WILSONFACILITY TYPE:
735
ADDRESS:21236 FIBRE COURTTELEPHONE:
(818) 448-3012
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 4CENSUS: 4DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rosemary Edeh, StaffTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and the purpose of the visit was explained to DSP Staff, Rosemary Edeh. Administrator, John Wilson, arrived shortly thereafter. The facility is licensed for (4) adults, ages 18 - 59, ambulatory only. The home is vendorized by the San Gabriel/Pomona Regional Center.

The facility consists of 3 client bedrooms, 1 Staff office, 2 bathrooms, living room, dining room, and kitchen. The spacious backyard consists of a shaded area for clients. There are no pools or bodies of water on the premises. The facility is operating within the fire clearance approval. Staff are providing care and supervision to meet the clients' needs and assisting in activities of daily living when needed. There are currently 4 ambulatory clients residing at the home. There are sufficient number of staff to provide care and supervision in all the shifts. The facility staff are wearing gloves while assisting clients. Staff are cleaning and disinfecting during each shift and more often for high touched surfaces. The cleaning supplies are locked in the garage storage cabinet. Facility has sufficient PPE supplies. There are sufficient food supplies of 2 day perishable and a week of non-perishable items observed. Foods are properly stored in the refrigerator to avoid contamination. LPA reviewed records for 4 staff. The files all contain the required documentation. Staff have health screening forms with TB test results, current CPR and First Aid certificates, Personnel record, employee rights, and training hours. LPA reviewed all 4 Client files and they all have the required documents. There are no clients who require postural supports and any prohibited or restricted health conditions. The emergency and disaster plan has at least 2 shelter locations and location of utility shutoff valves. The facility is currently conducting monthly/bimonthly fire drills. LPA informed the administrator about the different emergency scenarios drills that shall be conducted at least quarterly for each shift.

No deficiencies were observed during the visit today. LPA provided a technical assistance indicated on the LIC9102 form. An exit interview was held. A copy of this report along with the LIC9102 form were given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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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