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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803774
Report Date: 09/30/2024
Date Signed: 09/30/2024 11:36:59 AM

Document Has Been Signed on 09/30/2024 11:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KOKUA HOMEFACILITY NUMBER:
216803774
ADMINISTRATOR/
DIRECTOR:		MARTIN, GAMALIEL DANFACILITY TYPE:
735
ADDRESS:1380 JOYCE STTELEPHONE:
(415) 895-6941
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Madonna Ganir, House Manager
Gamaliel Martin, Administrator		TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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09/30/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 4 clients in care. All clients were leaving for day program during arrival. Administrator, Gamaliel Martin arrived later during the visit.

At approximately 9:15am, LPA and House Manager toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available for clients located in the hallway closet. Water temperature in sinks accessible to clients in care were measured at 107.4 F and 108.7 F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 05, 2024. Smoke/Carbon Monoxide detectors located throughout the facility are hard wired and were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in the kitchen and were found to be locked and secured. LPA observed First-Aid kit to be fully stocked and have all required items. Facility has a food menu and activities calendar along with games located in the living room for clients to use. Facility had extra supplies such as Personal Protective Equipment located in the garage. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facilities last fire and disaster drill was conducted 09/02/2024. Cash resources were documented and reviewed.



Continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KOKUA HOME
FACILITY NUMBER: 216803774
VISIT DATE: 09/30/2024
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At approximately 10:00 am, LPA conducted a review of 4 client records. All records had the required documentation.

At approximately 11:00 am, LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC400- Cash Affidavit for Clients
Copy of Lease Agreement

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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