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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803990
Report Date: 07/06/2023
Date Signed: 07/06/2023 10:22:39 AM

Document Has Been Signed on 07/06/2023 10:22 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NYUMBANI HOMEFACILITY NUMBER:
236803990
ADMINISTRATOR:GIKUHI, JOTHAMFACILITY TYPE:
735
ADDRESS:1560 SAUTERNE PLTELEPHONE:
(707) 540-3240
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 4CENSUS: 4DATE:
07/06/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Judith KarhoroTIME COMPLETED:
10:30 AM
NARRATIVE
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to continue the Annual Required inspection for this facility. LPA met with Administrator Jotham Gikuhi and Judith Karhoro. At approximately 8:30AM, LPA reviewed 4 of 4 Client records and 4 Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled. Administrator's Certificate was current.
LPA retested the water temperature in the client bathroom and found it to be still above the regulation of 105 to 120 degrees F.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LPA received copy of Surety Bond during visit.

Control of property documentation
LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- updated Disaster Plan

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with and Judith Karhoro and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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Document Has Been Signed on 07/06/2023 10:22 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 07/06/2023 at 10:06 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NYUMBANI HOME
FACILITY NUMBER: 236803990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on temperature testing in clients bathroom, the licensee did not comply with the section cited above in 1 of 1 client bathroom. The water temperature measured above 120 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee adjusted hot water thermostat during visit. Licensee will test temperature twice daily for 7 days and document temperature on a log showing temperatures within regulation. Temperature log to be submitted to CCL by POC date of 07/17/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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