366408869-7-8-2026-56-AS-LFAW-DVSUZW-20260708160213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366408869
Report Date: 07/08/2026
Date Signed: 07/08/2026 04:02:35 PM

Document Has Been Signed on 07/08/2026 04:02 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 HOME		FACILITY NUMBER:	366408869
ADMINISTRATOR/ DIRECTOR:	PENDING		FACILITY TYPE:	735
ADDRESS:	1532 N. MULBERRY AVE.		TELEPHONE:	(909) 877-9159
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY: 4		CENSUS: 4	DATE:	07/08/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:14 AM
MET WITH:	Yusif Rizk, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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On 7/8/2026 at 9:14 AM, Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA was granted entry to the facility by Administrator Yusif Rizk. Upon arrival LPA was informed by Yusif that he was scheduled for an appointment with a client and was running behind. LPA asked was there anyone else available to assist with today visit and Yusif stated, no. LPA proceed to complete the attempted visit report. Yusif came to the car and stated he might need to reschedule the appointment and he would know more information in approximately 10 minutes or so, and inquired if I am available to wait. Yusif returned to the car and stated he rescheduled the clients appointment and we can complete the visit. At the time of the visit there was one (1) staff present, one (1) client present and three (3) clients were attending the Day Program. The facility is a four (4) bedroom, two (2), bathroom home, with staff office, kitchen/dining area, living room, with attached garage. The facility is an Adult Residential Facility (ARF) vendorized by Inland Regional Center. Licensed capacity is (4) current census (4). LPA was accompanied by Yusif Rizk, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees F. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean. LPA observed the second restroom that is used by staff and clients with the light switch broken and doesn't turn off. Yusif stated it recently happened and he would be getting it repaired. A Deficiency cited.

***Continued on LIC809C***

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KONA HOME	FACILITY NUMBER: 366408869
	VISIT DATE: 07/08/2026

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LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 105. and 115.5 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside staff office inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed 2 out of 2 client file for admission agreement, medical assessment/physician report, IPP, MARs, and P&I audit. The facility records appears to be maintain and in order without any discrepancies. LPA reviewed and audited 3 out of 3 staff files, for Criminal Background Clearance, Health Screening, TB Test results, Training's, CPR/First Aid and CPI Certificate. LPA completed the audit and zero discrepancies were found. LPA advised Administrator to ensure all staff files are available for review even for staff that work at Kona Home occasionally. LPA reviewed the facility files for Insurance, (LIC 9282) Infection Control Plan,(LIC610D), Emergency Disaster Plan, Fire Drills, and Poster for reporting requirements. LPA observed the Infection Control Plan and Emergency Disaster Plan had not been reviewed and signed. Two (2) Technical Violations issued.

During today visit 1 deficiency 2 technical violation were issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report, LIC809, LIC809C, LIC809D, LIC9102TV, and appeal rights was discussed and copies were provided to Yusif Rizk, Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/08/2026 04:02 PM - It Cannot Be Edited

Created By: Lavette Farlow On 07/08/2026 at 02:44 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
RIVERSIDE, CA 92507

FACILITY NAME: KONA HOME	FACILITY NUMBER: 366408869
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not ensuring that 1 out of 2 bathrooms light switch is operational which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/15/2026
	Plan of Correction
1 2 3 4	Administrator agrees to complete a statement of understanding for the regulation cited above and discuss with staff about reporting repairs so the facility is maintained and in good repair. Administrator will complete the repairs to the light switch by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:

	Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026

LIC809 (FAS) - (06/04)

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