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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804296
Report Date: 07/24/2025
Date Signed: 07/25/2025 09:05:44 AM

Document Has Been Signed on 07/25/2025 09:05 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: 1DATE:
07/24/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:House manager Lourdes-Caregiver TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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At approximately 9:30 AM Licensing Program Analysts (LPA) Stevenson conducted a post-licensing inspection and was greeted by house manager Lourdes Soller, who has has Designation of Facility Responsibility (DFR) and also has her Administrator's certificate. Lourdes spoke with licensees Iris Baratas and Katherine Apostol who gave permission for Lourdes Soller to continue with post-licensing inspection. The facility is a one-story home with a fire clearance for 4 ambulatory clients, one of which one may be non-ambulatory. Bedroom 4 is cleared for non-ambulatory client.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean, without odors and comfortable temperature with bedroom doors free from obstruction. LPA noted a computer station, games, arts and crafts, televisions and music. LPAs observed fire extinguishers throughout the facility which were observed to be fully charged and last inspected September 2024. House manager was asked to arrange for updated inspection of fire extinguishers. Cleaning products, sharp items, other toxins and chemicals are kept out of client access and found secured in the garage and storage closet. House manager had difficulty using the key to unlock the electronic door of their medicine closet and it was recommended that facility program this electronic door for all staff, to make full time compliance easier.

Additional supply of hygiene products available to clients. Water was measured at 119 degrees and it was recommended water heater be turned down slightly to ensure faucets used by clients are within regulation between 105 & 120 degrees during the hottest days and house manager turned down the water heater control slightly during inspection. LPA noted that both bathrooms now have grab bars and anti-slip mats.
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. LPA confirmed the contents of the facility's First Aid Kit were sufficient. Facility had emergency lights and there is generator at their sister facility they will need to move to current location. It is recommended they have a separate generator for each owned facility.
Continued on 809C


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NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KENJI'S HOME
FACILITY NUMBER: 486804296
VISIT DATE: 07/24/2025
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Continued from LIC809
At approximately 10:15 AM LPA reviewed one (1) client and five (5) staff files. House manager was reminded of the requirement to have staff files on hand in the facility at all times. 5 of 5 staff records have required documentation. One pending staff member is shown to be in the process of being associated/cleared in Guardian to work at the facility and house manager was reminded of the requirement to not let individuals work in the facility until cleared on Guardian to do so.

Facility recently admitted their 1st client on 07/18/2025 with TB clearance, behavioral plan, and admissions agreement and have an appointment for their MD physical tomorrow. House manager was advised to ensure that a copy of their IPP be attained from regional center and that they attain a consent for emergency medical treatment (LIC627C), Identification numbers (ID) (LIC601) and signed Personal Rights (LIC613). In addition the house manager was advised to have the facility develop an Appraisal & Needs and Service Plan (LIC625) for their client. "No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs as specified in Sections 80068.2 and 85068.2."

Facility has a centrally locked storage areas for medicines and monies but their current client is on no medicines and does not have P&I money.

Licensee to submit updated documents by 08/23/2025

LIC 500 (updated staff roster)

LIC 9020 (updated client roster)

LIC 610D (emergency disaster plan IF CHANGES with staffing or plan on the LIC610D)

LIC 308 Designation of Facility Responsibility.

No deficiencies cited today, advisories are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code.

Exit interview conducted with house manager. Signature on form confirms receipt of documents

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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