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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804077
Report Date: 12/16/2022
Date Signed: 12/16/2022 03:46:11 PM

Document Has Been Signed on 12/16/2022 03:46 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 HOMES, LLCFACILITY NUMBER:
486804077
ADMINISTRATOR:KAMAU, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1455 MARSHALL ROADTELEPHONE:
(951) 742-1850
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 0DATE:
12/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Josephine KamauTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted a pre-licensing inspection on 12/16/2022. LPA met with Applicant, Josephine Kamau (6040197740 exp. 1/09/24), who will be the Administrator when the facility is licensed. Once licensed this facility will operate as a residential care facility that serves individuals with intellectual disabilities. This facility will be requesting vendorization from North Bay Regional Center.

On 11/01/22 the facility was granted a fire clearance approval from the Vacaville Fire Department for a capacity of 4 Non-Ambulatory clients. The facility is one-story with 4 bedrooms for client usage, 2 bathrooms, garage, living room, dining room, office, kitchen, sun room/activity room, and laundry room.

LPA and applicant toured the facility to ensure health and safety and that COVID-19 protocols were in place and made the following observations: Facility has a designated visitation area and will be allowing for visitation in resident rooms per CCL guidance. Upon entry there is a screening station for visitors that included hand sanitizer, a thermometer and a sign in sheet that included a questionnaire with standard Covid-19 screening questions. Visitors temperatures will be recorded on log sheet. Signs were posted to encourage droplet precaution and proper hand washing techniques throughout the facility and at the entrance. Facility has at least a 30 day supply of personal protective equipment. In the event that a client needs to quarantine, they're able to quarantine in the prospective bedrooms.

Smoke and carbon monoxide detectors were tested and appeared to be operational. The fire extinguisher was not tagged with it's last day of service. Applicant will show that the fire extinguisher has been serviced and send proof to LPA. All exits were unobstructed. The applicant submitted an emergency disaster plan that has been approved. The applicant has designated at least two emergency disaster location.

Continued onto 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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: AMANI HOMES, LLC
FACILITY NUMBER: 486804077
VISIT DATE: 12/16/2022
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First aid kit had all components required per regulation. Emergency lighting was available in the hallways. Bedrooms were furnished with chairs, dressers, beds with padding and appropriate lighting. Bathroom's had hand washing supplies and paper products were available. Water temperature in faucets used by residents measured at 117 & 116. There was an ample supply of linens, dishes and cooking supplies. There was a sufficient amount of cleaning supplies and hygiene products available. LPA observed adequate emergency food and water supply. Toxins will be secured behind locked magnetic cabinets. Medication will be locked in a medication cart.

LPA conducted a COMP III with applicant some of the following items were discussed: Administrator Qualifications, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Criminal Background clearance, Acceptance and Retention, Guardian, Restricted and Prohibited Health Care Conditions.

This pre-licensing is complete. LPA will submit the pre-licensing reports to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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