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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830784
Report Date: 08/18/2022
Date Signed: 08/18/2022 11:29:56 AM

Document Has Been Signed on 08/18/2022 11:29 AM - 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:AMANI DAY SERVICESFACILITY NUMBER:
496830784
ADMINISTRATOR:CATIIS, REGINALD ROSSFACILITY TYPE:
775
ADDRESS:5420 STATE FARM DR SUITE ATELEPHONE:
(707) 791-3290
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 30CENSUS: 8DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Reginald Catiis-AdministratorTIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Dina Alviso, arrived to conduct a Required- 1 Year inspection and met with Administrator Reginald Catiis. This inspection will focus on the Infection Control procedures and practices of this facility.

Fire clearance is approved for thirty (30) non-ambulatory. LPA observed all exits free from obstruction. Fire extinguishers (2) were serviced and tagged as required, dated 2/23/22. Administrator has submitted the Infection Control Plan that was recently required; The Administrator stated that he will be submitting an addendum to the control plan regarding "monkey pox". There were 8 clients attending day program services during this inspection. There were seven(7) staff, and the Administrator on duty during the LPA's inspection. All visitors and staff are screened upon entry; Temperatures are taken, and screening questions are asked before being allowed to remain in the facility, all information is logged. Clients are screened daily, and observed for any changes, all information is logged. LPA observed the facility to be clean, orderly, and at a comfortable temperature. Toxins are stored in locked cabinets. There is a medication cabinet that locks making medications inaccessible to clients in care. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for use by staff, visitors, and clients in care. Administrator and all staff were observed to be wearing appropriate masks during the LPA's inspection.

LPA observed two over the counter medication bottles of vitamin C, one large 1000mg and one small 500mg; The staff stated they were his personal bottles of Vitamin C. LPA discussed regulations regarding medications, including over the counter supplements, all are to be locked and secured at all times. This will be cited, Health Related Services 80075(j)(3)-see LIC89D.
The following deficiency was 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. Appeal Rights provided to the Administrator.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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Document Has Been Signed on 08/18/2022 11:29 AM - It Cannot Be Edited


Created By: Dina Alviso On 08/18/2022 at 11:03 AM
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: AMANI DAY SERVICES
FACILITY NUMBER: 496830784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(j)(3)
80075
Health Related Services
(j) Medications shall be centrally stored under the following circumstances:(3)Because of physical arrangements and the condition or the habits of persons in the facility, the medications are determined by either the administrator or by the licensing agency to be a safety hazard.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observationof two bottles of over the counter supplements being left out in the kitchen area of the day program making them accessible to clients in care, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
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Licensee to ensure that all medications including any over the counter medications and supplements are locked and secured at all times, making them inaccessible to clients in care. Submit plan of how the facility will secure all medcations, over the counter medications and supplements, including staff's personal medications, and how the facility will ensure future compliance with this regulation. POC due 8/19/22.
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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022


LIC809 (FAS) - (06/04)
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