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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
490105006
Report Date:
09/15/2022
Date Signed:
09/15/2022 02:24:49 PM
Document Has Been Signed on
09/15/2022 02:24 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 HOME
FACILITY NUMBER:
490105006
ADMINISTRATOR:
KENNEMER, KENNE
FACILITY TYPE:
735
ADDRESS:
5874 LONE PINE ROAD
TELEPHONE:
(707) 823-4019
CITY:
SEBASTOPOL
STATE:
CA
ZIP CODE:
95472
CAPACITY:
4
CENSUS:
3
DATE:
09/15/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:56 PM
MET WITH:
Kenne Kennemer (Licensee)
TIME COMPLETED:
02:27 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with Licensee Kenne Kennemer. The purpose of this case management inspection is to follow up on a death certificate to Community Care Licensing (CCL) dated 8/15/22. LPA requested Death Certificate due to client not on hospice.
Community Care Licensing previously followed up on Death report dated 6/16/2022 reporting C1 had an unexpected death. Per death certificate issued by Sonoma County Coroner case# SD 220616005 dated 8/15/22 it was determined that C1's cause of death was Asphyxia by accident due to obstruction of airway by food bolus.
During today's visit LPA conducted interviews with staff that revealed that C1 did not have any food restrictions and was able to communicate their needs. LPA reviewed C1's records including Physician's Report dated 4/14/21 and C1's care plan dated 1/18/22. Based on records review of C1's file revealed that C1 had been seen by their Physician in a regular basis and their IPP dated 11/1/21 indicates that C1 did not have any history of eating disorder and was not in a special diet.
The Department conducted an investigation into the unexpected death of client. The investigation found the facility followed all regulation and training requirements.
No deficiencies cited during today's visit.
SUPERVISORS NAME
:
Bethany Moellers
LICENSING EVALUATOR NAME
:
Marisol Cuadra
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/15/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/15/2022
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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