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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800764
Report Date: 07/25/2023
Date Signed: 07/25/2023 01:49:21 PM

Document Has Been Signed on 07/25/2023 01:49 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:
07/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Shawn Rooney-CaregiverTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Alviso conducted Required- 1 Year visit, on 7/25/23 at approximately 8:25am, and met with Shawn Rooney, caregiver. The Administrator was contacted by Shawn to notify them of the LPA's arrival. The Administrator arrived shortly after they were contacted. Currently there are six clients in care. All but one(1) client was picked up by day program transportation; Five of the clients attend day program.

Facility has a fire clearance for six(6) ambulatory. All twelve(12) smoke alarms were working properly when checked during the inspection; The facility has two(2) smoke alarms that are also carbon monoxide detectors. Fire extinguishers, three(3) were all serviced and tagged as required. All exits were clear and unobstructed.

LPA toured the facility with the Administrator. The hot water was checked at 116.9F which is within regulation. LPA observed a sufficient supply of food. The LPA observed a sufficient supply of cleaners, hygiene products, and paper products. Medications are locked up in a cabinet making them inaccessible to clients in care. Cleaners/toxins were all locked up making them inaccessible to clients in care. LPA observed a sufficient supply of linen for client use. The facility has sufficient furnishings for clients use. The large backyard has a soundproof music room shed for client use; There is an in-ground pool that is gated and kept locked inaccessible to clients in care. Facility has a small office in the backyard. The facility was clean and orderly, including the backyard area.

LPA reviewed six(6) client files. All files were complete.
LPA reviewed six(6) staff files. All staff had required criminal record clearance. All staff had annual training. All staff had current First Aid & CPR certification.

Continued LIC809C.....
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 PARK
FACILITY NUMBER: 496800764
VISIT DATE: 07/25/2023
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LPA requested the following forms be submitted by 8/25/23:
Personnel Report
Designation of Responsibility
Affidavit Regarding Client Cash Resources
Copy of Surety Bond
Emergency Disaster Plan
Infection Control Plan

There are no deficiencies cited today.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC809 (FAS) - (06/04)
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