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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804296
Report Date: 03/11/2025
Date Signed: 03/11/2025 11:05:21 AM

Document Has Been Signed on 03/11/2025 11:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KENJI'S HOMEFACILITY NUMBER:
486804296
ADMINISTRATOR/
DIRECTOR:		APOSTOL, KATHERINEFACILITY TYPE:
735
ADDRESS:1420 STARR COURTTELEPHONE:
(650) 333-9568
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
03/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Applicants, Iris Baratas and Katherine ApostolTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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
On 03/11/2025 Licensing Program Analysts (LPAs) Deniz and Felias conducted a pre-licensing inspection and was greeted by Applicants, Iris Baratas and Katherine Apostol. This pre-licensing inspection is being conducted for an initial licensing. The facility is a one-story home with a fire Clearance has been approved for 4 ambulatory of which one may be Non-ambulatory. Bedroom 4 is cleared for Non-ambulatory resident/client.

LPAs conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. LPAs observed Fire extinguishers throughout the facility which were last inspected November 2024. Cleaning products, sharp items, other toxins and chemicals are kept out of client access and found secured in the garage and storage closet.
Additional supply of hygiene products available to clients. Water was measured at 112.4 and 105.9 degrees F in faucets used by clients which is within regulation between 105 & 120 degrees F.
LPAs observed one out of two bathrooms did not have grab-bars. Applicants Baratas and Apostol agreed to make a request from their maintenance man to add grab-bars in bathroom. LPAs also observed that both bathrooms did not have non-slip bath mats. Applicants stated they are purchasing mats today. Applicants to send proof of grab-bars and non-slip mats within 7 days.
Emergency exits along the right side of the facility and were found to be unobstructed. Facility has combination smoke and carbon monoxide detectors which were operational during visit. LPAs confirmed that contents of the facility's First Aid Kit were sufficient. Facility had emergency lights and one generator were available on site for power outages.
ARF Component III was reviewed with Applicants.

No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Adult Residential Facility. LPAs will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicants of Status.

Exit interview conducted. Copy of report discussed and provided to Applicants. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1