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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803752
Report Date: 08/25/2021
Date Signed: 08/27/2021 09:36:47 AM

Document Has Been Signed on 08/27/2021 09:36 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:KWANZA HOMEFACILITY NUMBER:
496803752
ADMINISTRATOR:MBUGUA MWICHIGI, MICHAELFACILITY TYPE:
737
ADDRESS:1839 ALAN DRTELEPHONE:
(707) 665-5705
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 4CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Michael Mwichigi - Licensee/AdministratorTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced annual required inspection to this facility and was welcome by licensee/administrator Michael Mwichigi. Facility has 4 clients and 4 staff at this time. Facility has all 4 clients in zoom day programs and facility has plan activities for the clients in the facility.

LPA arrived at the facility and observed hand sanitizer at entrance and temperature was checked and logged in to a binder. Facility has a log in binder for temperature of clients and visitors. During tour the facility on 08/25/2021 with licensee Michael M.l, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 6/21. Facility smoke detectors and carbon monoxide are working properly during this visit. Hot water temperature was measured in client’s bathroom faucets and licensee/administrator understands that hot water temperature must be within Title 22 acceptable regulation of 105 to 120 degrees F. Toxins are stored in locked cabinets in laundry and below kitchen sink. Dangerous items were stored inaccessible to develop disabled clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathrooms designated for clients at the facility were supplied with individual towels; hand soap dispenser was available. All four client’s bedrooms have lighting & appropriate furnishings. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32-ASC & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19)

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: KWANZA HOME
FACILITY NUMBER: 496803752
VISIT DATE: 08/25/2021
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Infection Control:
Facility has submitted a mitigation program plan that has been approved at this time. Posters have been placed at facility and entrance has hand sanitizer designated for visitors and staff as they come into the facility. Facility has PPE supply stored in the garage of the facility. Facility has hired new staff and no new clients have been admitted since COVID-19. Clients’ medications are stored and locked in a cabinet in the facility kitchen. Facility has a 30-day supply of medication for clients. Clients aren’t wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Facility is working towards acquiring N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster drills have been conducted with the last on 6/28/2021.

There were no deficiencies cited at this time.

Department is requesting the following documents to be submitted to CCL by 9/1/2021:

LIC 400
LIC 402
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC809 (FAS) - (06/04)
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