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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803537
Report Date: 03/26/2024
Date Signed: 03/26/2024 04:26:53 PM


Document Has Been Signed on 03/26/2024 04:26 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
SANTA ROSA RO, 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:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator Mercedes VegvaryTIME COMPLETED:
04:41 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Mercedes Vegvary. Facility contact information was reviewed.

At approximately 9:45am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPA discussed with Admin that all open food items must be covered and labeled with date opened. Kitchen cabinet containing cleaning supplies was locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 106.1 degrees F which is within the allowable range of 105 to 120 degrees F.

Facility has 3 fire extinguishers all of which were last inspected during LPA visit today 3/26/2024. Carbon Monoxide detectors were tested and operational as indicated by inspection sticker by fire alarm on March 2023, LPA verified with Santa Rosa Fire Equipment Service Inc technician that facility will have the next service on 3/29/2024, appointment confirmed. Per LPA observation and Admin interview, facility’s quarterly disaster drills are performed with staff individually; however, the facility has not conducted a disaster drill for every employee within the past quarter. Per Health and Safety Code (HSC) 1569.695(c) A facility shall conduct a drill at least quarterly for each shift...documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill (deficiency cited, see 809D). Facility has a backup generator for use during a power outage.

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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: KENWOOD GREENS
FACILITY NUMBER: 496803537
VISIT DATE: 03/26/2024
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Continued from 809...

At approximately 11:30 am LPA conducted a review of seven [7] resident records. Four [4] out of seven [7] residents (R3, R4, R6, and R7) did not have current Appraisals. Per Title 22 regulation 87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first...(deficiency cited, see 809D).

At approximately 2:00pm LPA conducted a review of five [5] staff records. Per LPA and Admin review of Guardian roster, staff (S1) does not yet have fingerprint clearance, it is "In Process" per the Guardian roster. S1 has been employed at at facility beginning 8/23/2022. Per Title 22 regulation 87355(d) Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted (deficiency cited, see 809D. Civil Penalty assessed). LPA advised Admin all employees must have fingerprint clearance in order to work at the facility. Admin agrees to have S1 cease working at the facility until fingerprint clearance is obtained and Guardian roster shows S1 as "Eligible-Clearance." S1 immediately left facility and ceased working.

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the kitchen. LPA and Admin observed pre-poured medications filled in respective residents' pill boxes for the next day and evening. Per Title 22 regulation 87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers (deficiency cited, see 809D).

Mercedes Vegvary Administrator certificate 6003396740 expires 6/30/2025. Julius Vegvary Administrator certificate expired 2/18/2023; per LPA review Admin cert for Julius is currently in pending status. All fees are current as of this time.



LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.


Continued on 809C(2) ...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: KENWOOD GREENS
FACILITY NUMBER: 496803537
VISIT DATE: 03/26/2024
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Continued from 809C...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Current lease
Liability Insurance

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

Exit interview conducted with Administrator and a copy of this report was given

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/26/2024 04:26 PM - It Cannot Be Edited

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: KENWOOD GREENS
FACILITY NUMBER: 496803537

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that per LPA and Admin review of Guardian roster, staff (S1) does not yet have fingerprint clearance, it is showing as "In Process" per the Guardian roster. S1 has been employed at at facility beginning 8/23/2022. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Admin agrees to have S1 cease working at the facility until fingerprint clearance is obtained. Admin agrees that Admin will verify S1 has fingerprint clearance and shows as "Eligible Clearance" before they return to the facility. Per LPA obsevation S1 immediately left facility and ceased working. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 03/26/2024 04:26 PM - It Cannot Be Edited

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: KENWOOD GREENS
FACILITY NUMBER: 496803537

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed pre-poured medications filled in respective residents' pill boxes for the next day and evening, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Admin to submit LIC9098 self-certifying that they will immediately stop pre-pouring medications. Admin will conduct staff training to ensure staff are aware that the facility does not engage in pre-pouring medications. Admin to submit training log along with LIC9098 by plan of correction due date.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Admin interview, the licensee did not comply with the section cited above in that four [4] out of seven [7] residents (R3, R4, R6, and R7) did not have current Appraisals.which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Admin to consuct resident appraisals for R3, R4, R6, and R7, review appraisal with resident's responsible party and obtain either signature or electronic method of verification via email that the appraisal was reviewed with the residents' responsible party or parties. Admin to submit current appraisals along with method of verification for the R3, R4, R6, and R7 to CCL by plan of correction due date.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/26/2024 04:26 PM - It Cannot Be Edited

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: KENWOOD GREENS
FACILITY NUMBER: 496803537

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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 observation and Admin interview along with LPA and Admin record review, the licensee did not comply with the section cited above in that per LPA observation and Admin interview, facility’s quarterly disaster drills are performed with staff individually; however, the facility has not conducted a disaster drill for every employee within the past quarter. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Admin to conduct facility’s quarterly disaster drill with every staff member and submit to CCL the disater drill log showing documentation of the drills which shall include the date of the drill, the type of emergency covered by the drill, and the names of staff participating in the drill, by plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6