<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804296
Report Date: 08/19/2025
Date Signed: 08/19/2025 10:53:56 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2025 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20250731155754
FACILITY NAME:KENJI'S HOMEFACILITY NUMBER:
486804296
ADMINISTRATOR:APOSTOL, KATHERINEFACILITY TYPE:
735
ADDRESS:1420 STARR COURTTELEPHONE:
(650) 333-9568
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 2DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:House Manager- Lourdes SollerTIME COMPLETED:
11:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff do not ensure the facility is free of pests
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 10:15 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with House Manager Lourdes Soller.
During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of “Facility staff do not ensure the facility is free of pests.” Complaint alleged the facility has been experiencing an ant infestation in the food and kitchen cabinets. Complaint alleged that ants in the coffee creamer located in the cabinet and that the facility suggested using an alternative creamer.

During unannounced visit on 08/05/2025, LPA conducted a walkthrough of the facility kitchen and took photos. LPA observed the following: facility fridge and facility cabinets were clean. LPA did not observe any ants in the facility fridge or facility cabinets. LPA observed that the facility had options for coffee creamer such as powdered creamer and milk.
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250731155754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KENJI'S HOME
FACILITY NUMBER: 486804296
VISIT DATE: 08/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099
Interview conducted with Licensee stated that the facility retains a monthy pest control company at a sister facility and intends to have them begin at Kenji's home now that they are licensed and have accepted their first client. On 08/19/2025 LPA observed and obtained a record of a pest intervention performed by Orkin on 08/11/2025. Interview also revealed that staff have observed some ants in the facility, but they are quick to take care of of the ants using sponges and cleaning products. LPA observed cleaning products and sponges readily available during visit.

Based on observations made and interviews conducted, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to House Manager Loudes Soller.
Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2