385600235-10-10-2024-14-AS-DTOA-D9WRNT-20241010131051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600235
Report Date: 10/10/2024
Date Signed: 10/10/2024 01:11:41 PM

Document Has Been Signed on 10/10/2024 01:11 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	KOKORO ASSISTED LIVING		FACILITY NUMBER:	385600235
ADMINISTRATOR:	CHANTELLE HUDSON		FACILITY TYPE:	740
ADDRESS:	1881 BUSH ST		TELEPHONE:	(415) 776-8066
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	61	CENSUS: 46	DATE:	10/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Chantelle Hudson, Executive Director & Angie Esplana		TIME COMPLETED:	01:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/10/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Executive Director, Chantelle Hudson & Business Office Director, Angie Esplana. The facility currently provides care for 46 residents, 2 of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor, kitchen and common spaces were found to be charged. Smoke and carbon monoxide detectors and fire safety systems were present and recently serviced by fire inspection agency. There was a sufficient supply of both perishable and nonperishable foods as required, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished constantly throughout the week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, and housekeeping carts all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. During inspection LPA observed a maintenance cart containing power tools and other items that could pose potential safety risk located in the 5th floor stairwell. Each stairwell exit is unlocked but has a auditory alarm when opened. No residents were observed on the floor or near the maintenance cart when found. Maintenance staff immediately removed and secured items. Residents that were out in the community during the inspection were observed interacting with staff, fellow residents and visitors in the common areas. The facility encourages regular family visits and utilizes a variety of activities with LPA observing residents utilizing activity spaces and items. There is a single outdoor patio for resident use, all equipped with appropriate shading Continued onto LIC809-C

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KOKORO ASSISTED LIVING	FACILITY NUMBER: 385600235
	VISIT DATE: 10/10/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA conducted a sample file review for residents and found all items to be in order including needs & service plans and physician's reports. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR completed. Executive Director and Business Office Manager are currently in progress to complete all staff annual training records. Facility utilizes Allen Flores approved training vendor with training records currently over 50% completed. Executive Director agreed to provide proof of completion for all required training by 11/6/2024. Technical Violation issued. Lastly, A spot check of medications including narcotic was conducted and found that all medication counts and records to be in order.

Chantelle Hudson's Administrator Certificate is currently active through 7/17/2025.
LPA requested the following documents be sent to CCL by COB 10/24/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Liability Insurance

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/10/2024 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KOKORO ASSISTED LIVING	FACILITY NUMBER: 385600235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 in 1 of 1 maintenance cart containing powertools and other potentially dangerous items to residents with dementia, accessible in facility stairwell adjacent to resident bedrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Licensee failed to ensure items that could constitute danger to residents were kept secured and inaccessible. Executive Director requested for Maintenance staff to immediately remove and secure maintenance cart during visit. Deficiency cleared at the time of visit.

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.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3