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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803986
Report Date: 11/21/2023
Date Signed: 11/21/2023 03:50:05 PM


Document Has Been Signed on 11/21/2023 03:50 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: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:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Administrator, Kennedy WainainaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Victoria Wainaina, Licensee and Kennedy Wainaina, Administrator. Facility currently has five (5) residents in care none of which are currently on hospice.

At approximately 2:40pm LPA and Licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. Kitchen cabinet containing cleaning supplies was locked. Sharp knives drawer locked and inaccessible to residents.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks accessible to residents in care measured at 109 in room #5, 109 in room #4, resident in room #3 was sleeping so temperature not taken, 106.5 in room #2, and 108.7 in room #1, degrees F respectively, which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 03/20/23. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors in private rooms as well as in dining room and on front door have an auditory alert system that were all functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 10/10/23. Facility has a backup generator for use during a power outage.

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

LPA unable to complete annual inspection today and so will return at a later date to complete.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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