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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210114
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:04:51 PM

Document Has Been Signed on 01/20/2023 12:04 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:KONANIA HOUSE 2FACILITY NUMBER:
419210114
ADMINISTRATOR:PATRICIA WILLIAMS-SWINTFACILITY TYPE:
735
ADDRESS:468 SAN DIEGO AVENUETELEPHONE:
(650) 994-1934
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 6CENSUS: 4DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jesse SwintTIME COMPLETED:
12:15 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual required 1 year inspection focused on COVID infection control. LPA met the husband of the licensee Jesse Swint who is applying for new ownership of this facility.

Upon entry LPA was COVID screened and had temperature taken. LPA did observe COVID postings on the front entryway but advised posting those items as well on the front door prior to entry. LPA toured facility's building and grounds. LPA observed COVID postings upon entry of the facility at the COVID station near the front door. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is in place as of today's visit. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Fire extinguishers are observed through out the facility as fully charged. Facility has fire sprinklers in place through out the facility. LPA observed two fire extinguishers and all are charged and dials read as within specifications. Facility lighting is sufficient for residents and staff safety. Water temperature is tested at 112F in upstairs full bathroom. On the lower level there are two more bathrooms with non-skid mats in place. Liquid soap is available and paper towels are available in resident bathrooms. Two resident rooms are observed and they are equipped with the required furniture and light fixtures. First-aid kit is complete. A Disaster and Mass Casualty Plan is posted. Staff are observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact is reviewed. Administrator certificate hours are observed as current. All staff and residents are fully vaccinated and all boosters.

Continued on attached LIC809-C
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2
FACILITY NUMBER: 419210114
VISIT DATE: 01/20/2023
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Page 2 - Required 1 Year Annual


The following updated forms are requested to be submitted to CCLD by 01/27/2023:

• LIC 308 Designation of Facility Responsibility
• LIC 400 Affidavit Regarding Client/Resident Cash Resources
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Copy of updated Surety Bond
• Copy of updated administrator certificate

No citations issued. Report is reviewed with Jesse Swint.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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