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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804077
Report Date: 10/24/2023
Date Signed: 10/24/2023 02:33:38 PM


Document Has Been Signed on 10/24/2023 02:33 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:AMANI HOMES, LLCFACILITY NUMBER:
486804077
ADMINISTRATOR:KAMAU, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1455 MARSHALL ROADTELEPHONE:
(951) 742-1850
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:4CENSUS: 4DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Josephine KamauTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Amani Homes, LLC for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Josephine Kamau, and was granted access into the facility.

LPA and Licensee toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on December 2022 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in residents bathroom measured at 116 degrees, and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Activities Menu was also posted. Medications were centrally stored and locked. Medications orders were reviewed and found to be appropriate during the inspection. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Emergency Disaster Plan was discussed. Quarterly Disaster Drill was last conducted October 10, 2023.

During the Required 1 year inspection, LPA reviewed 4 of 4 resident files and found those to be appropriate during the review. LPA reviewed 5 of 5 staff members files and found those to be appropriate during the review. LPA interviewed 3 of 3 staff members. LPA attempted to interview 4 of 4 residents in care, but was unsuccessful. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AMANI HOMES, LLC
FACILITY NUMBER: 486804077
VISIT DATE: 10/24/2023
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LPA requested the following documents to be sent:

LIC 500-Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Liability insurance
Control of Property
Resident Roster

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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