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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801810
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:51:22 AM

Document Has Been Signed on 08/13/2024 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SENECA HOUSEFACILITY NUMBER:
496801810
ADMINISTRATOR/
DIRECTOR:
KAMAU, JOYCE M.FACILITY TYPE:
735
ADDRESS:2821 SENECA LANETELEPHONE:
(707) 579-5751
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 4DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Joyce Kamau-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA), Alviso is conducting an Required-1 Year inspection, on 8/13/24 at approximately 9:00am, and met with Administrator Joyce Kamau.

Currently four (4) clients in care. Facility has an approved fire clearance four (6) ambulatory clients. All client rooms are private. The facility will only accept four (4) clients into care, per Licensee/Administrator. The facility has operated with four (4) clients in care for the last several years.

One of the resident rooms is now used as a staff room. Administrator to submit updated facility sketch, and application form LIC200, no later than 8/19/2024. Once the documents are received by Licensing, the LPA will ensure an updated fire clearance is obtained.

The facility does have a required infection control plan. The facility does have a required emergency disaster plan. Facility had an evacuation fire drill on July 16, 2024.

LPA reviewed four (4) client files. Files were complete.
LPA reviewed two (2) staff files. Staff had criminal record clearance as required. Staff had first aid and CPR certification as required. Staff had required training.

Facility had a sufficient food supply. Medications were locked and inaccessible to clients in care. Sufficient cleaners/disinfectants, paper products, hygiene products, and linens. Facility had a sufficient supply of furnishings for client use. Disinfectants/cleaners were locked and inaccessible to clients in care. Facility was clean and orderly. The facility was observed to be at a comfortable temperature. Sufficient lighting in hallways, bathrooms, resident rooms, and common areas. Hot water was checked at 119.2 degrees Fahrenheit, which is within regulation. Administrator understands to monitor the water to help ensure it doesn't go over 120. degrees Fahrenheit.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SENECA HOUSE
FACILITY NUMBER: 496801810
VISIT DATE: 08/13/2024
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LPA is requesting the following documents be updated and submitted by 9/14/2024
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review, if any updates submit a copy of plan- please ensure to date and sign last page and submit if no changes)
Infection Control Plan (ensure to review, if any updates submit a copy of plan- please ensure to date and sign last page and submit if no changes)
Copy of LIC400 Handling of Client Cash Resources (complete the form- include copy of surety bond if handling cash)
Copy of Surety bond
Resident Roster
Copy of current Administrator Certificate.

There were no deficiencies cited during today's inspection.

Exit interview held with Administrator Joyce Kamau.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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