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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408869
Report Date: 12/19/2023
Date Signed: 12/19/2023 03:55:28 PM

Document Has Been Signed on 12/19/2023 03:55 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 3DATE:
12/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Chuks Ikechukwu, DSPTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility initiate the complaint investigation for complaint control number 56-AS-20231218095440. LPA met with direct support provider (DSP) Chuks Ikechukwu who was informed of the reason for the visit. LPA phoned Administrator Fausto Reyes and informed them of LPA's purpose for visiting. Administrator Reyes stated that they were not able to meet with LPA in person at the facility.

During today’s visit, LPA was unable to review any staff records and LPA was unable to receive requested staff records due to files are not accessible during this visit. This pose a potential health and safety risk to clients in care. Refer to LIC 809D for deficiency cited.

An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to DSP Ikechukwu.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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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Document Has Been Signed on 12/19/2023 03:55 PM - It Cannot Be Edited


Created By: Anna Bueno On 12/19/2023 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: KONA HOME
FACILITY NUMBER: 366408869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
80066(a)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
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Licensee shall, at all times, provide a means to allow access for staff file review as requested by the authorized agency. Access means, but is not limited to, keeping staff files available for review or leaving a key to access files with staff on duty. Correction shall be satisfied no later than the end of POC day.
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Based on LPA Anna Bueno observation and Administrator Fausto Reyes interview, the licensee did not comply with the section cited above LPA was not able to review staff records due to no staff on site has access to staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
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