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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803774
Report Date: 07/14/2022
Date Signed: 07/15/2022 06:54:53 AM

Document Has Been Signed on 07/15/2022 06:54 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:KOKUA HOMEFACILITY NUMBER:
216803774
ADMINISTRATOR:MARTIN, GAMALIEL DANFACILITY TYPE:
735
ADDRESS:1380 JOYCE STTELEPHONE:
(415) 895-6941
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 4DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gamaliel Martin - AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility was welcome by staff. Staff contacted administrator Gamaliel Martin who arrived during this visit. LPA during this visit. Clients were present during the visit. There is no outside day program at this time due to short staffing. They are doing zoom activities and day program has been visiting facility. There are activities planned for clients during the day if they want to participate and outings.

LPA arrived at the facility and observed a check in for staff and visitor’s by the entrance door. During facility tour on 7/14/2022 with administrator Gamaliel Martin, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/2021 at the time of the visit. Smoke detectors test was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored locked in a cabinet inside the garage. LPA observed that dangerous items were locked. There was a supply of cleaners, hygiene products and paper products available for clients. Sample of client’s bedrooms were inspected and had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucet measured between 108.9 degrees F and 111.7 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills have been conducted quarterly and last dated 6/2/22.

Continued LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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: KOKUA HOME
FACILITY NUMBER: 216803774
VISIT DATE: 07/14/2022
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Infection Control:
Facility has submitted a COVID-19 mitigation program plan that has been approved and infection control plan has been submitted. Some posters have been placed at facility, container with hand sanitizer and other items designated for visitors and staff are at entrance. Staff before coming into work has temperature checked. Facility has some PPE supply stored in the facility garage area. Clients’ medications are stored and locked in large kitchen cabinet. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Facility is allowing visitors and clients have available virtual and telephone calls when contacting with family members and others. Per administrator all PPE training required is on file and all staff has acquired N-95 fit testing.

There were no deficiencies cited at this time.

Department is requesting Licensee to update the following documents and submit to CCL by 07/21/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate
Copy of this annual Smoke Detector & Carbon Monoxide Inspection
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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