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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803986
Report Date: 10/21/2021
Date Signed: 10/21/2021 02:09:23 PM

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:SUMMERFIELD HOME CAREFACILITY NUMBER:
496803986
ADMINISTRATOR:WAINAINA, KENNEDYFACILITY TYPE:
740
ADDRESS:2725 SUMMERFIELD RD.TELEPHONE:
(415) 408-1603
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: DATE:
10/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Victoria and Kennedy WainainaTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Erik Gonzalez-Campos arrived announced, to conduct a Pre-Licensing Inspection and met with applicants, Victoria and Kennedy Wainaina.

LPA and Applicants toured the inside of the facility and grounds. Facility is a one-story residence with five single occupancy bedrooms, 5 private half bathrooms and one common bathroom, an office and common areas. Resident bedrooms have required furnishings, such as a dresser, night stand, lamp and bed linens. Bathroom shower has non-skid shower floor and grab bars for safety. LPA confirmed that contents of the facility First Aid Kit were sufficient. Water temperature in resident bathroom read at 107.6 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility locks centrally stored medications in a kitchen cabinet. Resident and staff files are stored in the office. Cleaning supplies and toxins are locked in a cabinet under the kitchen sink and in the garage. Perishable and non-perishable foods observed per regulation.

Facility received an approved fire clearance dated July 12, 2021 that allows for six non-ambulatory residents. Facility has space indoors and outdoors for client activities.

Component III reviewed with applicants.

LPA will notify Application Unit so application process may proceed.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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