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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408869
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:53:18 PM

Document Has Been Signed on 08/04/2023 04:53 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KONA HOMEFACILITY NUMBER:
366408869
ADMINISTRATOR:PENDINGFACILITY TYPE:
735
ADDRESS:1532 N. MULBERRY AVE.TELEPHONE:
(909) 877-9159
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 4DATE:
08/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Fausto Reyes, AdministratorTIME COMPLETED:
04:50 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Kona Home Adult Residential Facility for an unannounced case management visit. This visit is in response to an Special Incident Report called in to the Community Care Licensing Office on 8/3/23. LPA knocked on the door, was greeted by staff and granted entry. LPA was informed that the Administrator was not at the facility at the time. Staff contacted Administrator, Fausto Reyes and provided LPA the phone to speak to him. Administrator informed LPA that he has left for the day. Administrator left the Incident Report and Witness statements in a folder for LPA to collect. Administrator agreed to submit additional information to LPA on the following Monday, (8/7/23)

LPA completed a walk through of the facility. LPA informed that the resident census is 4. LPA observed no concerns for health and safety. No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Facility Representative, Carru Watson
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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