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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408869
Report Date: 07/31/2023
Date Signed: 07/31/2023 03:14:16 PM

Document Has Been Signed on 07/31/2023 03:14 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:
07/31/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Fausto Reyes - AdministratorTIME COMPLETED:
03:16 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced Proof of Correction (POC) visit for deficiencies cited on form LIC9099-D issued on 07/14/2023.

During this visit, LPA reviewed facility files. LPA observed and verified the following:
  • Deficiency 80066(a) cited per Title 22 Division 6 of the California Code of Regulations has been cleared. Licensee complied with the terms of the POC by LPA was able to review all staff files during today's visit.
  • Deficiency 80068(a) cited per Title 22 Division 6 of the California Code of Regulations has been cleared. Licensee complied with the terms of the POC.
  • Deficiency 80070(b)(10) cited per Title 22 Division 6 of the California Code of Regulations has been cleared. Licensee complied with the terms of the POC as LPA reviewed completed medication training.

Letters of Cleared POC were issued during today's visit. This report was reviewed with and a copy was provided to Administrator Reyes.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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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