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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803752
Report Date: 04/28/2026
Date Signed: 04/28/2026 03:13:36 PM

Document Has Been Signed on 04/28/2026 03:13 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:
04/28/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Administrator Peter KoriTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At approximately 1:45 PM Licensing Program Analyst (LPA) arrived unannounced on a case management visit related to a self-reported Incident report received by Community Care Licensing on 04/14/2026 and met with Administrator Peter Kori. LPA notes that Community Care Licensing (CCL) had also received an earlier call from Administrator Peter Kori on 04/12/2026 to report the incident.

The incident report stated that on 04/12/2026 on the PM shift, staff (S1) accidentally administered client (C1) a double dose when a PM dose was given and then a PM dose of the same medicine to be dosed out the next night was also given to C1. Report of the error was reported to client (C1's) family, Physician, Poison control, Residential Service Provider, as well as, the North Bay Regional Center.

Distraction of S1 by C2 was cited by the facility as the reason for the error. An audit by staff (S3) discovered the error and alerted the administrator, the house nurse and the facility sought the advice of poison control and C1 had their vitals checked every 30 minutes and fluids were encouraged by report for the remainder of the PM shift and then hourly on NOC shift with C1 noted to eat 100% of their breakfast, ambulating normally and not seeming to suffer any adverse effects. Facility is noted to have a similar medication error on 11/22/25 with distraction of caregiver cited as the reason.

During today’s Case Management visit, LPA conducted an interview, made observations and obtained documents.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2026
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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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: 04/28/2026
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continued from LIC809

Because medicines were not administered per Physician's directions as required by regulation 80075(b)(5)(B), a Type A citation and Plan of Correction for violation of CCR 80075(b)(5)(B) is being issued (See LIC809D)

Deficiencies are sited form California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency by Plan of Correction due date and/or repeat the deficiency within a 12 month period may result in civil penalties.

Copy of report, LIC809D, LIC811 (confidential names), and appeal rights were discussed and provided to staff.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/28/2026 03:13 PM - It Cannot Be Edited


Created By: Star Stevenson On 04/28/2026 at 02:12 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: 04/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2026
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B) Health Related Services:
Clients shall be assisted as needed with self-administration of ...prescription medications. (5)...providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions
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Licensee informed that S1 will not assist with medication administration until S1 has had re-training on Medication Administration Procedures, including distraction management is complete and submit proof of training conducted to CCL by POC due date 04/29/2026
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This requirement was not met as evidenced by: Based on document review, interview, Licensee did not comply with the section cited above as C1 was administered an accidential double dose of a medicine. This poses an immediate health and personal rights risk to clients in care.
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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:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
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