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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803990
Report Date: 06/19/2024
Date Signed: 06/19/2024 12:52:58 PM

Document Has Been Signed on 06/19/2024 12:52 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NYUMBANI HOMEFACILITY NUMBER:
236803990
ADMINISTRATOR/
DIRECTOR:
GIKUHI, JOTHAMFACILITY TYPE:
735
ADDRESS:1560 SAUTERNE PLTELEPHONE:
(707) 540-3240
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 4CENSUS: 3DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jotham GikuhiTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Jotham Gikuhi and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Water temperature in clients restroom measured above regulation. Staff and resident files were reviewed. First Aid/CPR certification was current. Medications were also reviewed. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting drills every 3 months.

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 Administrator and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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Document Has Been Signed on 06/19/2024 12:52 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 06/19/2024 at 12:21 PM
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: 06/19/2024

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 measurements, the licensee did not comply with the section cited above. Client restroom sink water temperature measured above regulation. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee adjusted hot water heater during visit. Licensee to conduct twice daily temperature readings for 7 days and submit temperature log to CCL by POC date of 06/28/2024.
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: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
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