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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803752
Report Date: 09/03/2024
Date Signed: 09/03/2024 12:40:24 PM

Document Has Been Signed on 09/03/2024 12:40 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:KWANZA HOMEFACILITY NUMBER:
496803752
ADMINISTRATOR/
DIRECTOR:		PETER KORIFACILITY TYPE:
737
ADDRESS:1839 ALAN DRTELEPHONE:
(707) 665-5705
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 4CENSUS: 4DATE:
09/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Michael Mwichigi - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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09/03/2024, Licensing Program Analysts (LPA) Loera and Alviso conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility is an enhanced behavioral. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently four(4) residents in care. Facility approved for four(4) non-ambulatory.

At approximately 9:30am, LPAs and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. LPAs observed a clients room with broken/missing blinds (Deficiency Cited). Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 113.2 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected May, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients in care were found to be locked and secured in a cabinet located in the kitchen.

At approximately 10:45 am, LPAs conducted a review of four(4) client records. All records had the required documentation. P&I monies were documented, secure and not commingled.



At approximately 11:15 am, LPAs conducted review of four(4) staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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: KWANZA HOME
FACILITY NUMBER: 496803752
VISIT DATE: 09/03/2024
NARRATIVE
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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
LIC309- Administrative Organization
LIC400- Cash affidavit for clients
LIC610D- Emergency disaster plan (review - if any changes - send to CCLD)
Infection Control Plan (review - if any changes - send to CCLD)
Copy of Surety bond
Copy of Administrator Certificate

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2024 12:40 PM - It Cannot Be Edited


Created By: Anthony Loera On 09/03/2024 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KWANZA HOME
FACILITY NUMBER: 496803752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of one. Blind slates were broken/missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Administrator to ensure to repair/replace blinds in client room so it ensures client privacy as well as compliance with property maintenance as per regulation. POC due 10/01/2024.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Anthony Loera
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
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