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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804208
Report Date: 07/09/2024
Date Signed: 07/09/2024 12:01:20 PM

Document Has Been Signed on 07/09/2024 12:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:IKA HOMES LLCFACILITY NUMBER:
216804208
ADMINISTRATOR/
DIRECTOR:		KAMWESIGYE, IVANFACILITY TYPE:
735
ADDRESS:365 ALAMEDA DEL PRADOTELEPHONE:
(818) 256-4465
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 4CENSUS: 0DATE:
07/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Ivan KamwesigyeTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a pre-licensing inspection and was greeted by Ivan Kamwesigye, Administrator. At approximately 9:30am LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature.

Facility is a one story residence with four bedrooms, one which will be used as a staff bedroom. Facility has two bathrooms, a living room and dining room, a garage and a large backyard. Client rooms were not furnished per regulation at this time, and Administrator agreed to obtain appropriate furnishings per regulation before license is granted. Water temperature read at 132 degrees F which is not within regulation of 105 & 120 degrees F. Administrator turned down water heater. Smoke and carbon monoxide alarms were located throughout the facility and were tested and operational during inspection.

Facility has sufficient items for cooking, however there is not sufficient food. Facility intends to store medications in a locked kitchen cabinet. Facility intends to store confidential records in a locked hall closet. Cleaning supplies and toxins are locked in a cabinet above the laundry. Facility intends to lock knives in the kitchen drawer. LPA and Administrator spoke about the various types of locks and how they can be used in the facility. Facility has areas inside and outside for visiting and activities.

Facility received an approved fire clearance dated 05/07/2024 that allows for up to four ambulatory residents. LPA observed fire extinguishers missing service tags. Administrator advised that fire extinguishers were brand new and the Fire Department advised Administrator that they do not need service tags at this time. LPA observed a locked gate on the side yard. Admin to prove correspondence from Novato Fire Department indicating that the fire extinguishers do not require a service tag at this time, and that it has been approved to keep the side gate locked.
Continued on LIC809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IKA HOMES LLC
FACILITY NUMBER: 216804208
VISIT DATE: 07/09/2024
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Continued from LIC809

The following items to be corrected and or obtained prior to LPA submission of facility's application for approval:
-Bedroom furniture in all bedrooms (bed, chair, lamp, dresser)
-Fire departments approval for locked gate (or remove the lock)
-Clean up overgrown grass/debris outside
-Plan indicating how administrator will ensure the hill outside will not be a safety hazard to clients in care
-Sufficient towels and linens
-Sufficient cleaning supplies
-Emergency food and water
-Trash bins with tight fitting lids for bathrooms
-Hand soap in each bathroom and single use towels
-Outdoor furniture
-Sufficient PPE
-All chemicals and toxins locked above laundry, and any additional chemicals kept locked in the garage
-Water temperature within range allowed per regulation.

LPA and Administrator discussed that the facility must be ready for clients to move in at the time of licensure. Administrator to provide photos of items. Once acceptable photographic proof is received by CCL, LPA will submit facility's application for approval.

Comp III reviewed and exit interview conducted with Administrator and a copy of this report given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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