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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803986
Report Date: 03/03/2022
Date Signed: 03/03/2022 04:01:20 PM


Document Has Been Signed on 03/03/2022 04:01 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: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: 5DATE:
03/03/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensees/Administrator, Kennedy and Victoria WainainaTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 3/3/2022 to conduct a post licensing inspection. LPA was initially greeted by staff who screened LPA for COVID symptoms. LPA met with licensees/administrator Kennedy and Victoria Wainaina. Currently there are 5 residents in care none of which are on hospice and some who have a diagnosis of dementia. LPA observed auditory devices functioning on the front door and on the doors exiting to the backyard.

The amount of fresh and nonperishable foods appeared to be within regulation. LPA observed non perishable food in garage cabinets. Toxins are secured and inaccessible in locked garage cabinets. Medications are locked and centrally located in a kitchen cabinet. LPA reviewed medication record which was current. LPA recorded a water temperature of 107.6 degrees which is within regulation of of 105 and 120 degrees F at faucets accessible to residents. Food is available for residents any time of the day. Bathrooms were equipped with necessary grab bars and non-slip floors/mats and appeared to have sufficient hygiene products. Fire extinguisher inspected was charged and dated 4/2/2021. Smoke detectors and carbon monoxide detector were operational, devices had fresh batteries per administrator. LPA observed required postings (LTCO, CCL Complaint poster) in addition to COVID-19 postings. Facility is screening visitors at the front door which includes taking temperatures and requiring visitors to wear masks.

LPA reviewed 5 out of 5 resident files. LPA observed current need/services plans and appraisals. 4 out of 5 resident files had admission agreements listing the information for the previous license. LPA provided guidance to obtain updated admission agreements with current license information.

Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SUMMERFIELD HOME CARE
FACILITY NUMBER: 496803986
VISIT DATE: 03/03/2022
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LPA reviewed 3 staff record and found that staff had current first aid and CPR training. LPA and administrator discussed annual training requirements for staff. LPA provided outline of necessary training.

Licensee stated disaster drills were conducted last month.

Kennedy Wainaina's Administrator Certificate 6059978740 expires 6/7/2023.


No deficiencies cited during today's inspection.

Exit interview conducted with licensee and a copy of this report emailed to the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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