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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800764
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:33:12 PM

Document Has Been Signed on 07/20/2022 12:33 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-ROHNERT PARKFACILITY NUMBER:
496800764
ADMINISTRATOR:ROONEY, MARGOFACILITY TYPE:
735
ADDRESS:7527 BORIS COURTTELEPHONE:
(707) 795-3706
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 6DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Margo Rooney-AdministratorTIME COMPLETED:
12:32 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dina Alviso conducted 1 year required inspection and met with Administrator Margo Rooney. The inspection is focused on the Infection Control procedures and practices of this facility.

There are six(6) clients in care. Clients are screened daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins/cleaners are stored in locked cabinets making them inaccessible to clients in care. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to clients in care. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for staff use as required; PPE supplies are available to clients for use as needed. Administrator recently submitted the Infection Control Plan as required. Fire clearance is approved for six (6) ambulatory.

LPA observed the staff on duty not wearing a mask as required. LPA discussed the mask requirement with the staff person (S1) who did put on a mask right away when the LPA asked them to. Deficiency will be cited, 80072(a)(2) Personal Rights-see LIC809D. LPA arrived at the facility and was let in by the staff person on duty (S1) and was not screened as required. Deficiency will be cited, 80064(s)(3) Administrator -Qualifications and Duties-see LIC809D.
The following citations are being issued under Title 22, Division 6 of the California Code of Regulation. Appeal Rights given.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 12:33 PM - It Cannot Be Edited


Created By: Dina Alviso On 07/20/2022 at 11:47 AM
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-ROHNERT PARK
FACILITY NUMBER: 496800764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of staff without a mask as required the licensee did not comply with the section cited above in one out of one staff on dut, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Licensee to hold an in-service training with all staff regarding the mask requirement for all staff at all times; Licensee to submit proof of training by 7/27/22. Licensee to submit the plan of correcting the deficiwncy by 7/21/22.
Type A
Section Cited
CCR
80064(a)(3)
Administrator -Qualifications and Duties (a)The administrator shall have the following qualifications:(3) Knowledge of and ability to comply with applicable law and regulation.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in screening requirements, the LPA was not screened, temperature was not taken and/or questions asked of the LPA/visitor, upon their arrival and entry into the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Licensee to hold an in-service training with all staff regarding screenings of all visitors and staff as required. Licensee to submit proof of training by 7/27/22. Licensee to submit the plan of correction by 7/21/22.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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