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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803752
Report Date: 08/19/2025
Date Signed: 08/19/2025 04:10:37 PM

Document Has Been Signed on 08/19/2025 04:10 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
CCLD Regional Office, 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:
08/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Michael Mwichigi, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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08/19/2025, Licensing Program Analysts (LPA) Hansen conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility is an enhanced behavioral. Facility is a single story with 4 bedrooms. There are currently four(4) clients in care. Facility approved for four(4) non-ambulatory. LPA met with the Licensee Michael Mwichigi as Administrator was unavailable.

At approximately 10:40 am, LPA and Licensee 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. LPA observed a clients room with broken/missing blinds and approximately 16 holes client has made in walls throughout the facility (see pics & LIC809-D). Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 112.8 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected July 17, 2025. 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; although there were multiple cans of paint on floor of garage and Clorox wipes on counter of laundry room, accessible to clients in care (see pics & LIC 809-D).

At approximately 12:30 pm, LPA conducted a review of four(4) client records. All records had the required documentation. P&I monies were documented, secure and not commingled.


Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/19/2025 04:10 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/19/2025 at 02:44 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 finding there were multiple cans of paint on floor of garage and Clorox wipes on counter of laundry room, accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Facility to submit LIC9098 self- certifying they will ensure Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients by POC due date 8/20/2025
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/19/2025 04:10 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/19/2025 at 02:44 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: 08/19/2025

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 & there were over 16 holes client made in walls throughout facility which poses/posed a potential health, safety or personal rights risk to persons in care.****$250. Civil Penalty for repeat in less than 12 months
POC Due Date: 09/19/2025
Plan of Correction
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Licensee to ensure to repair/replace blinds in client room so it ensures client privacy as well as compliance with property maintenance as per regulation as well contact property owner /NBRC and get a plan to fix as clients can't live with this. POC due 9/19/2025 Submit pictues of blinds & plan to CCL/LPA to clear citation.
Type B
Section Cited
CCR
89965(k)(1)
Personnel Requirements
(1) Direct care staff shall maintain current certifications in first aid and cardiopulmonary resuscitation. The administrator shall maintain the certifications in the facility personnel records.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with Licensee, the licensee did not comply with the section cited above in 1 out of 4 staff records reviewed did not have current CPR/1st Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licnesee to submit current CPR/1st Aid for self to CCL/LPA by POC due date 8/29/2025 to clear citation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KWANZA HOME
FACILITY NUMBER: 496803752
VISIT DATE: 08/19/2025
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Continued from LIC809

At approximately 2:00pm LPA conducted medication review of 2 of 2 clients centrally stored, finding 1 of 2 not having all medications logged. (see LIC9021 TA) & for medication needing destruction follow FDA Flush list and Pharmacy advisory.
At approximately 1:30 pm, LPA conducted review of four(4) staff records/training. Upon a review of staff records, LPA found 4 out of 4 staff to have required annual and initial training, although 1 out of 4 did not have current 1st Aid & CPR certification on file (see LIC809-D).

Administrator Certificate for Peter Kori # 7026524735 expires 1/7/2027. Disaster drills have been conducted quarterly with the last being 7/30/2025.

***$250 civil penalty assessed for repeat of citation 80087(a) in less than 12 months (given 9/3/2024).

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..

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)
LIC9020 Register of Facility Client’s
Copy of Surety bond
Copy of Administrator Certificate

Exit interview conducted with Licensee and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
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