486804296-2-10-2026-21-AS-SSTN-DR6SFN-20260210125038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804296
Report Date: 02/10/2026
Date Signed: 02/10/2026 12:58:53 PM

Document Has Been Signed on 02/10/2026 12:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	KENJI'S HOME		FACILITY NUMBER:	486804296
ADMINISTRATOR/ DIRECTOR:	APOSTOL, KATHERINE		FACILITY TYPE:	735
ADDRESS:	1420 STARR COURT		TELEPHONE:	(650) 333-9568
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 2	DATE:	02/10/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Lourdes Soller-House Manager		TIME VISIT/ INSPECTION COMPLETED:	01:10 PM

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	At approximately 10:10 AM Licensing Program Analysts (LPA) Stevenson arrived unannounced to perform a required 1-year inspection and was greeted by caregiver Tricia-Ann Alinea (Beltran) who has has Designation of Facility Responsibility (RP), House Manager Lourdes Soller was called who arrived at approximately 10:30 AM to assist with today's inspection. The facility is a one-story home with a fire clearance for 4 clients, one of which one may be non-ambulatory. Bedroom 4 is cleared for the non-ambulatory client. Currently their are two (2) clients in care, both of whom were home at the time of today's inspection. 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. LPA observed fire extinguishers throughout the facility which were observed to be fully charged and last inspected September 2025. Cleaning products, sharp items, other toxins and chemicals are kept out of client access and found secured in the garage and storage closet. Facility now has two (2) locking closets, locking utensil drawer and locking doors under the kitchen ink. Additional supply of hygiene products available to clients. Water available to clients in care was measured within allowable regulation 105 & 120F. 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 has 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

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026

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: 02/10/2026

NARRATIVE

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Continued from LIC809
House manager Lourdes Soller states that the facility performs quarterly Emergency and Disaster Drills but two additional staff members present cannot recall drills performed and no documentation of drills are present for inspection and a Technical Violation of HSC 1565(C) is being levied.

At approximately 11:30 AM,LPA reviewed two (2) client and 2 of two have all required documentation.
At approximately 11:45 AM LPA reviewed four (4) of 4 staff files and found all 4 to have the required documentation including criminal clearance, TB testing and 1st/Aid/CPR training.

P&I monies were found to be secured and correctly accounted for.

Medicines were found to be centrally stored and secure, however the Medicine Administration Record (MAR) on hand for one (1) client had evidence of a med given in three instances that were not documented and a fourth incident that indicated the a PM med had been given during my noon 12:00PM visit and a Type B citation is being levied for a violation of CCR 80075(b)(5)(C) which requires, "Clients shall be assisted as needed with self-administration of prescription and nonprescription medications...A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response"

Licensee to submit updated documents by 03/08/2026

LIC 500 (updated staff roster)

LIC 9020 (updated client roster)

LIC 610D (emergency disaster & disaster plan)

LIC 308 Designation of Facility Responsibility (typically for new staff)

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 House Manager Lourdes Soller and Appeal rights were given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/10/2026 12:58 PM - It Cannot Be Edited

Created By: Star Stevenson On 02/10/2026 at 12:20 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: KENJI'S HOME	FACILITY NUMBER: 486804296
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(b)(5)(C)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review the licensee did not comply with the section cited above in one (1) out of two (2) count client records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2026
	Plan of Correction
1 2 3 4	Licensee to review general reguation of 80075, as well as the specific regulation of 80075(b)(5)(C) and to provide training to all staff on the current LIC500 by POC date 02/20/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/10/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026

LIC809 (FAS) - (06/04)

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