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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490105006
Report Date: 02/28/2022
Date Signed: 02/28/2022 02:09:28 PM

Document Has Been Signed on 02/28/2022 02:09 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:KENNEMER HOMEFACILITY NUMBER:
490105006
ADMINISTRATOR:KENNEMER, KENNEFACILITY TYPE:
735
ADDRESS:5874 LONE PINE ROADTELEPHONE:
(707) 823-4019
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 4; 4CENSUS: 4DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Kenne Kennemer (Licensee)TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff, Patty Kennemer, Licensee Kenne Kennemer arrived later. LPA conducted a Risk Assessment call with staff. LPA/Licensee reviewed PIN 22-05, 22-06, 22-07 & 22-09.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathrooms are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least once a day. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and clients. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Clients do not attend to day program and facility provides activities for clients at home. Clients receive indoor visitation with their families and facility will perform antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 3/19/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff.
Licensee provided updates of the following: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), affidavit regarding client/resident cash resources (LIC400) surety bond and Emergency Disaster Plan (LIC610E).
No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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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