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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830784
Report Date: 09/03/2024
Date Signed: 09/03/2024 04:14:44 PM

Document Has Been Signed on 09/03/2024 04:14 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:AMANI DAY SERVICESFACILITY NUMBER:
496830784
ADMINISTRATOR/
DIRECTOR:
CATIIS, REGINALD ROSSFACILITY TYPE:
775
ADDRESS:5420 STATE FARM DR SUITE ATELEPHONE:
(707) 791-3290
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 30CENSUS: 24DATE:
09/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Reginald Catiis-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs), Alviso and Loera, conducted a Required-1 Year visit, on 9/3/24 at approximately 1:45pm; LPAs met with Administrator Reginald Catiis and Supervisor Erica De Vera. There are twenty-eight clients enrolled in the day program.

Facility fire cleared for thirty (30) non-ambulatory clients; Today there were twenty-four clients attending the day program.

LPAs reviewed five (5) client files.

LPAs reviewed five (5) staff files. All staff have criminal record clearance as required. Staff had required first aid, and CPR certification. Staff had required training.

Fire/emergency drills are conducted quarterly per review of the emergency binder,

LPAs toured the facility with the Administrator. Staff were getting clients ready to be leaving day program upon LPA's arrival. The facility was observed to be at a comfortable temperature. The facility was clean and orderly during the inspection.
All exits were unobstructed. Fire extinguishers, two (2), were serviced and tagged as required.
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.

Licensee to submit the following updated annual forms by 10/1/24.
LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Emergency Disaster Plan- updated & reviewed if needed- submit copy if changes
LIC400-Affidavit Regarding Client Cash Resources
LIC402-Surety Bond (if handling client cash)
Infection Control Plan-updated & reviewed if needed- submit copy if changes

No deficiencies cited today.

Exit interview conducted with the Administrator.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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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