<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601154
Report Date: 04/24/2024
Date Signed: 04/24/2024 07:35:07 PM

Document Has Been Signed on 04/24/2024 07:35 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:KONANIA HOUSE 2FACILITY NUMBER:
415601154
ADMINISTRATOR/
DIRECTOR:
SWINT, JESSEFACILITY TYPE:
735
ADDRESS:468 SAN DIEGO AVETELEPHONE:
(310) 406-9947
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 4CENSUS: 4DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Jesse SwintTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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 4/24/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Jesse Swint and explained the purpose of the visit..

LPA toured the facility including all of resident rooms, garage, and kitchen area. LPA observed all residents went to day program. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked and inaccessible to residents. Food supply was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill will is done every month.

Four resident records and two staff records were reviewed. Resident’s PNI money was counted and all accounted for with proper log and receipts. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans.

Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

LPA requested the following: LIC 308 Designation of Facility Responsibility & LIC 500 Personnel Report.

NO deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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 1