<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408869
Report Date: 08/04/2023
Date Signed: 08/07/2023 04:56:49 PM

Document Has Been Signed on 08/07/2023 04:56 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: 0DATE:
08/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Fausto Reyes, AdministratorTIME COMPLETED:
09:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Kona Home unannounced to gather more information about a Special Incident Report, (SIR) called in to the Community Care Licensing office on 8/3/23. LPA rang the doorbell, no answer to door, LPA spoke with staff at front door via Ring Doorbell Camera. Staff identified themselves as Administrator, Fausto Reyes, (FR) LPA introduced self and stated purpose of the visit. FR informed LPA that no residents or staff are at the facility at this time. The residents are at their Adult Day Programs. FR reported that staff and resident's are due to return this afternoon at 4pm.
LPA made note, then inquired about the SIR, as the incident was called in, no documentation. FR stated that the SIR was not sent because they did not finish until 7pm the night before. FR agreed to send a copy of that SIR via email.

9:29am LPA received a copy of the report from, FR. LPA confirmed it was received, thanked FR.
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)
Page: 1 of 1