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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408869
Report Date: 03/20/2025
Date Signed: 03/20/2025 06:35:31 PM

Document Has Been Signed on 03/20/2025 06:35 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KONA HOMEFACILITY NUMBER:
366408869
ADMINISTRATOR/
DIRECTOR:		PENDINGFACILITY TYPE:
735
ADDRESS:1532 N. MULBERRY AVE.TELEPHONE:
(909) 877-9159
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 4DATE:
03/20/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:31 PM
MET WITH:Jazmin Pressley, DSPTIME VISIT/
INSPECTION COMPLETED:
06:40 PM
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Licensing Program Analyst (LPA) LaVette Farlow arrived at the facility unannounced to conduct a Case Management Visit for health and safety. This case management visit is in response to a Special Incident Report (SIR) 56-AS-20231218095440 submitted to the Community Care Licensing Office. LPA was greeted by Staff, Jazmin Pressley at the front door. LPA introduced self and stated purpose of the visit.

During today's visit, LPA discussed the incident and surrounding events with DSP staff, conducted interviews with staff and residents. LPA did a health and safety check, tour of the facility and reviewed client records.

No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to Jazmin Pressley, DSP.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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