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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601154
Report Date: 04/19/2023
Date Signed: 04/19/2023 10:30:41 AM

Document Has Been Signed on 04/19/2023 10:30 AM - 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:KONANIA HOUSE 2FACILITY NUMBER:
415601154
ADMINISTRATOR:SWINT, JESSEFACILITY TYPE:
735
ADDRESS:468 SAN DIEGO AVETELEPHONE:
(310) 406-9947
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 4CENSUS: 4DATE:
04/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jesse SwintTIME COMPLETED:
10:40 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an announced pre-licensing inspection visit. LPA met with licensee Jesse Swint who is the new owner of the facility who will be leasing the property from the land owner.

LPA toured the facility's building and grounds. This is a two level home. Upper level is care staff quarters, kitchen, formal living room area, and the ground floor is where the residents live. LPA observed all resident rooms and they contain the required furniture outlined in regulations. All utilities are connected and functioning through out the facility during inspection. Egress routes are clear and easily definable, labeled with exit signs, and egress route maps within the physical plant. Egress and emergency exit routes are free and clear of obstructions. COVID postings are in place on the ground floor of the facility. Hand washing signs are posted in resident bathrooms. Water temperature is tested at 110F on the upper floor of the facility. LPA observed all resident rooms and they contain the required furniture outlined in regulations. Beddings and extra linens are observed in a storage cabinet in the garage. LPA observed the fire extinguisher on the lower level as being charged and within operating range.

LPA inspected the kitchen and dining room area. Dining room area is observed as clean and in order. Both fresh food and frozen food supplies are inspected and observed as in place in the kitchen. Dry goods/emergency food supplies are in place also being stored in the garage. LPA observed medications as being locked and stored in an upper cabinet in the kitchen. Knives are locked in the facility's office space adjacent to staff room. First aid kit is observed as in place adjacent to the kitchen stored in a closet by the front door. Resident medications are current and medications administration records as well. Resident temperatures are checked daily as well as staff.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued. LPA is recommending the license of the facility to be issued.

Report is reviewed with licensee Jesse Swint.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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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