496830784-9-25-2023-21-AS-DALO-CW22FF-20230925172128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496830784
Report Date: 09/25/2023
Date Signed: 09/25/2023 05:21:33 PM

Document Has Been Signed on 09/25/2023 05:21 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:	AMANI DAY SERVICES		FACILITY NUMBER:	496830784
ADMINISTRATOR:	CATIIS, REGINALD ROSS		FACILITY TYPE:	775
ADDRESS:	5420 STATE FARM DR SUITE A		TELEPHONE:	(707) 791-3290
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY: 30		CENSUS: 26	DATE:	09/25/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	02:39 PM
MET WITH:	Reginald Catiis-Administrator		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alviso conducted a continuation annual visit, on 9/25/23 at approximately 2:05pm, and met with Administrator Reginald Catiis, and Supervisor Erica De Vera. The LPA reviewed facility records. The facility does have an infection control plan, and an emergency disaster plan, as required. Per review of the emergency binder, last fire drill was conducted on July 11, 2023. LPA toured the facility with the Administrator. All exits were unobstructed. Fire extinguishers, two(2), were serviced and tagged, expire 1/27/24. The facility was clean and orderly during the inspection. Staff were getting clients ready to be leaving day program upon LPA's arrival. The LPA observed toxins to be stored inaccessible to clients in care. LPA observed that all medications were locked and inaccessible to clients in care. Bathrooms were clean, as well as all common areas. Staff were observed to be cleaning and disinfecting the day program once all clients were gone. The facility was observed to be at a comfortable temperature. Licensee to submit the following annual forms by 10/25/23: LIC500- Personnel Report LIC308- Designation of Responsibility LIC610D- Emergency Disaster Plan-updated & reviewed as needed LIC400-Affidavit Regarding Client Cash Resources LIC402-Surety Bond (if handling client cash) Infection Control Plan-updated & reviewed as needed Continued on LIC809C...

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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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Document Has Been Signed on 09/25/2023 05:21 PM - It Cannot Be Edited

Created By: Dina Alviso On 09/25/2023 at 04:43 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: AMANI DAY SERVICES	FACILITY NUMBER: 496830784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82065(g)(1)

Personnel Requirements

(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per file review, staff, S4 & S6, lack a required health screening report, including TB test results, the licensee did not comply with the section cited above in [2] out of [6] file reviews of staff,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff have the required health screening, inclluding TB test result information. Licensee to ensure that staff S4 & S6 obtain a health screening report with TB test & results. Submit copies of health screening, and TB test/results on S4 & S6 to the Licensing office by due date of 10/13/23.

Type B

Section Cited

CCR

82069(a)

Client Medical Assessments

(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per file review, client #3 & #5, lack a required medical assessment, the licensee did not comply with the section cited above in [2] out of [6t] client file reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that all clients have the required medical assessments. Licensee to ensure that clients C #3 & C #5 obtain a medical assessment, including TB test results. Submit copies of medical assessmentss on both clients to the Licensing office by due date of 10/13/23.

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:

Carla Martinez

LICENSING EVALUATOR NAME:

Dina Alviso

LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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: AMANI DAY SERVICES	FACILITY NUMBER: 496830784
	VISIT DATE: 09/25/2023

NARRATIVE

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LPA reviewed 6(six) client files. Per file review, client #3 & #5, lack a required medical assessment.

This deficiency will be cited, Client Medical Assessments- 82069(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan, see LIC809D.

LPA reviewed 6(six) staff files. The staff on-site all have criminal record clearance as required.
Per file review, staff, S4 & S6, lack a required health screening report, including TB test results.

This deficiency will be cited, Personnel Requirements-82065(g) (1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure, see LIC809D.

The following deficiency(s) 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: 09/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

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