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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600235
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:57:44 PM


Document Has Been Signed on 10/11/2022 03:57 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:KOKORO ASSISTED LIVINGFACILITY NUMBER:
385600235
ADMINISTRATOR:NAOKO JONESFACILITY TYPE:
740
ADDRESS:1881 BUSH STTELEPHONE:
(415) 776-8066
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:61CENSUS: 48DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Naoko JonesTIME COMPLETED:
11:30 AM
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On 10/11/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Administrator, Naoko Jones. LPA explained the purpose of the visit and LPA was screened at the front entrance.

The Director of Marketing and Administration provided a toured of the facility and grounds. This is a 6 story facility with resident apartments on all floors with 2 apartments reserved on the 1st floor for isolation purpose. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, daily screening records for staff, residents and visitors and staff training and policies.

During the tour, LPA observed resident apartments are equipped with emergency call system next to the bed and the bathroom which can be activated from bedroom and bathroom and residents also wear a call pendant. LPA observed bathrooms are equipped with soap and paper towels, and hand washing instruction is posted by the hand washing stations. COVID-19 signs are posted through-out the facility, in the elevators and hand sanitizer stations/dispensers installed by the elevator. PPE supply is adequate and stored on the 5th floor. Residents are observed wearing face masks and maintaining social distancing during activities.

Kitchen and food supplies are inspected. LPA observed refrigerator temperature measured at 28 degrees Fahrenheit (F) and freezer measured at -1 degree F.

First-aid kit is inspected and complete. Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety.

The following updated licensing forms or information are requested to be submitted to CCLD BY 10/13/22: LIC309 (Administrative Responsibility and LIC 308 (Designation of Administrative Responsibility).

No deficiency cited today. This report is reviewed and discussed with the Administrator.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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