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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803537
Report Date: 07/18/2023
Date Signed: 07/18/2023 11:25:44 AM


Document Has Been Signed on 07/18/2023 11:25 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:KENWOOD GREENSFACILITY NUMBER:
496803537
ADMINISTRATOR:VEGVARY, JULIUSFACILITY TYPE:
740
ADDRESS:340 GREENE STREETTELEPHONE:
(707) 483-0998
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:8CENSUS: 7DATE:
07/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee, Mercedes VegvaryTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Kenwood Greens for the purpose of conducting a Case Management-Other inspection. LPA was greeted at the door by Caregiver, Valentine Luna and granted access into the facility. Licensee arrived 5 minutes later.

During this Case Management-Other inspection, LPA observed Resident #1 in placement. Resident was observed to be sleeping and was unavailable for an interview. Licensee reported to the LPA that Resident #1 will be relocating to Minnesota by family request and not by an Eviction. Licensee and LPA had a discussion about Reporting Requirements and the importance of reporting incidents to CCL (See LIC 9102-Technical Assistance). Licensee understood the Reporting Requirements Regulation as outlined in Title 22.

Also during this Case Management-Other inspection, LPA discussed the LIC 200 for a Change of Mailing Address. LPA confirmed the address where mail is supposed to be forwarded to.

No deficiencies were observed or cited during today's Case Management-Other inspection. Exit interview was conducted with Mercedes Vegvary and a copy of the report was given to the Licensee.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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