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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490105006
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:59:11 PM

Document Has Been Signed on 02/03/2023 02:59 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: 4CENSUS: 3DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Patty Kennemer (Staff)TIME COMPLETED:
03:14 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
Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff Patty Kennemer. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected at least once per day. Facility does perform daily screening of staff and residents and documents it. Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Smoke Detectors and Carbon Monoxide detector were operational. Last disaster drill was conducted on December, 2022. All clients do attend to day program and facility provides activities for clients as well.

Administrator will provide copies of the following documents by 2/17/23: LIC 610 Emergency Disaster Plan, LIC 500 Personnel Summary, LIC400 affidavit regarding client cash resources and surety bond.

No deficiencies cited during today's inspection. Exit interview conducted with staff and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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