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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408869
Report Date: 07/14/2023
Date Signed: 07/14/2023 06:22:14 PM

Document Has Been Signed on 07/14/2023 06:22 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: 4DATE:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Francis Okonji - DSPTIME COMPLETED:
06:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno made an announced visit to the facility to conduct a required annual inspection. LPA identified herself to direct support provider (DSP) Francis Okonji who was advised of the purpose of the visit.

The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients. Four clients and two staff were present during this visit.

LPA Bueno and DSP Okonji toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded patio area for clients. LPA and DSP observed that side gate was unlocked and free of obstruction. The facility had a working telephone for client use. The facility fire extinguishers were last inspected on 01/30/2023. LPA and DSP tested three smoke alarms and one carbon monoxide detectors and found units to be in working order. A locked centralized cabinet is utilized for medications while client files are secured and locked in a standing closet. Sharps, toxins, and cleaning agents are kept locked and secured.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA and DSP observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens and towels. LPA and DSP observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients.
Kitchen and Dining Areas: LPA and DSP inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. The kitchen countertop, floors, and appliances were free from debris. LPA and DSP inspected food provisions and found a 2-day supply of perishable food and 7-day supply of non-perishable food.
Common (living/activity) areas: LPA and DSP observed adequate seating in the common areas. Each client room had a supply of personal enrichment activities. Calendar of activities were observed.

The following records were inspected:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: KONA HOME
FACILITY NUMBER: 366408869
VISIT DATE: 07/14/2023
NARRATIVE
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Client Records: LPA inspected four of four client files and found that one of four clients (C1) did did not have required documentation, including but not limited to, an admissions agreement and current Individual Program Plan (IPP). DSP attempted to find C1 missing record but only found one page of placement packet, the placement checklist.
Staff Records: LPA was not able to review any staff files during today's visit.
Centralized Medication: LPA reviewed four of four client medications. LPA and DSP observed that Client 3 has one of ten medications was marked as taken but not administered.
LPA also reviewed LIC 610E, emergency disaster plan, signed on 04/08/2021.

During today's inspection, LPA Bueno observed that Staff 1 (S1) does have background clearance from Department of Social Services for the adult and senior care program. This poses an immediate health and safety risk to clients in care. LPA was iinformed that S1 has worked at this facility since May 2023. A civil penalty of $500 was assessed on 07/14/2023.

Deficiencies were issued for staff not having backgound clearance, incomplete client records, inaccessible staff files, and medication not administered as prescribed. These deficiencies pose a potential health and safety risk to residents in care.

An exit interview was conducted where this report, LIC 809D, and appeal rights was discussed and copies were provided to facility staff at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/14/2023 06:22 PM - It Cannot Be Edited


Created By: Anna Bueno On 07/14/2023 at 05:37 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: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(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:
Deficient Practice Statement
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Based on LPA observations and staff 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.
POC Due Date: 07/21/2023
Plan of Correction
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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 unsecured or leaving a key to access files with staff on duty. Correction shall be satisfied no later than the end of POC day.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPS records review and staff interview, the licensee did not comply with the section cited above in one of four client records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee shall maintain complete and updated records for all clients in care. Correction shall be satisfied no later than the end of POC day.
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: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/14/2023 06:22 PM - It Cannot Be Edited


Created By: Anna Bueno On 07/14/2023 at 05:37 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: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and DSP observations, the licensee did not comply with the section cited above in one of ten Client 3 medications was marked as given but not administered, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA and DSP observed the tablet in the buble pack.
POC Due Date: 07/28/2023
Plan of Correction
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Licensee shall have an in-service training for all staff for administrating medication and submit proof of scope of training and training completion to CCL. Correction shall be satisfied no later than the end of POC day.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/14/2023 06:22 PM - It Cannot Be Edited


Created By: Anna Bueno On 07/14/2023 at 05:51 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: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a ...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations and records review, the licensee did not comply with the section cited above LPA observed Staff 1 (S1) working at the facility without background clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Licensee shall immediately remove S1 from the facility. LPA observed S1 leave the facility and another staff arrived to cover the shift.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023


LIC809 (FAS) - (06/04)
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