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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600235
Report Date: 10/12/2021
Date Signed: 10/12/2021 04:36:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 40DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Naoko JonesTIME COMPLETED:
12:30 PM
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On 10/12/2021, 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 Administrator and the Resident Service Director provided a toured of the facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, staff randomly testing records, resident and staff daily monitoring records, containment strategies (facility has reserved 2 private apartments with their own bathrooms and shower rooms on the first floor for isolation. quarantine purposes), PPE supply (the staff conducts weekly inventory count and the Resident Service Director orders the supplies accordingly on a weekly basis) and the environmental cleaning supply are adequate, bathrooms are equipped with soap and paper towels, and hand washing instruction is posted by the hand washing stations. Signs are posted through-out the facility. Residents are observed to be wearing face masks and maintaining social distancing during activities and meals. There are COVID-19 signs posted inside and outside of the elevator and hand sanitizer station outside.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety


No deficiency cited today. This report is reviewed and discussed with the Administrator and the Resident Service Director. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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