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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490105006
Report Date: 04/09/2024
Date Signed: 04/09/2024 02:39:27 PM

Document Has Been Signed on 04/09/2024 02:39 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/
DIRECTOR:		KENNEMER, KENNEFACILITY TYPE:
735
ADDRESS:5874 LONE PINE ROADTELEPHONE:
(707) 823-4019
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 4CENSUS: 3DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Patty Kennemer (staff)TIME VISIT/
INSPECTION COMPLETED:
02:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff Patty Kennemer. Clients were attending to day program during the visit.

LPA initiated a tour of the facility at 1:10 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client's bathroom measured at 114.4 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cleaning supplies were locked in a bathroom closet and under the kitchen sink. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked in a hallway closet along with client cash resources. Cash resources and their records were reviewed. Medications and medication records were reviewed. Smoke detectors were tested and operational. At approximate 1:30pm LPA/Staff observed fire extinguisher was last inspected February, 2023. Most recent disaster drill was conducted 11/28/2023.

File review was initiated at 2:00 pm. Three staff files and three client files were reviewed. Staff have required First Aid certificates and training hours required. Administrator Certificate for Licensee, Ken Kennemer, 6015398735, expires on 5/14/2024. Contact information was reviewed.

Licensee will provide copies of the following documents by 4/19/24: LIC 610 Emergency Disaster Plan (if there are any changes), LIC 500 Personnel Summary and surety bond.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

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: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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Document Has Been Signed on 04/09/2024 02:39 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/09/2024 at 02:28 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: KENNEMER HOME
FACILITY NUMBER: 490105006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 fire extinguisher was not serviced since February 2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee agreed to submit Proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department. POC due date 4/19/2024
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, records review and interview, the licensee did not comply with the section cited above in conducting and documenting a fire disaster drill since November 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee/Administrator will conduct a disaster/fire drill by POC date. Provide LIC9098 certifying the drill was completed along with documentation with day, time, and participants. Submit no later than 3/15/13
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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