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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804077
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:48:07 PM

Document Has Been Signed on 12/12/2024 03:48 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 HOMES, LLCFACILITY NUMBER:
486804077
ADMINISTRATOR/
DIRECTOR:		KAMAU, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1455 MARSHALL ROADTELEPHONE:
(951) 742-1850
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 3DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Josephine Kamau, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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At approximately 10:15 AM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection and were greeted by Staff 1 (S1) and Staff 2 (S2). Administrator, Josephine Kamau was contacted and arrived at approximately 10:45 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for four (4) and is approved for all non-ambulatory residents. Facility is vendorized with the North Bay Regional Center (NBRC).

At approximately 10:50 AM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of hygiene products, clean linens, paper products, and incontinent care briefs available to residents. LPAs advised Administrator to ensure that all trash cans in the facility are covered to remain in compliance with regulation. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. LPAs observed cabinets containing cleaning supplies (Clorox bleach powder, Lysol, detergents, carpet and floor cleaner, etc.) and other items that could pose a risk (knives, medications) with the magnet and keys used to unlock them stored accessible to residents in care, (see LIC809D). Administrator secured the magnets and keys immediately and installed additional locks bringing the facility into compliance. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a sun room and backyard space for activities. LPAs observed craft supplies and games for residents in care. Each resident has an internet access device and facility has internet available. Facility's telephone was tested and was operational.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AMANI HOMES, LLC
FACILITY NUMBER: 486804077
VISIT DATE: 12/12/2024
NARRATIVE
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Continued from LIC809...

Facility's fire extinguisher was observed charged and was last serviced 2/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Facility conducts quarterly disaster drills with the most recent drill conducted 9/2024. LPAs observed facility's infection control plan and emergency disaster plan which was last updated 7/2023. LPAs observed a supply of PPE, emergency supplies, a first aid kit, flashlights and backpacks for each resident for emergency preparedness. Administrator provided LPAs with a copy of the facility's current liability insurance.

At approximately 11:50 AM, LPAs reviewed three (3) staff files and three (3) resident files. Three (3) of three (3) staff files reviewed have all of the required paperwork and proof of current First Aid and CPR training. However, LPAs advised Administrator to ensure that proof of all completed staff training is maintained on site to remain in compliance. Three (3) of three (3) resident files reviewed have all the required paperwork. Administrator coordinates medical and dental visits for the residents and transportation to and from their appointments.

At approximately 2:00 PM, LPAs reviewed medications, and medication records which were observed not maintained in compliance with regulation, (see LIC809D). P&I is maintained in compliance with regulation. However, LPAs advised Administrator to increase their bond amount to bring the facility back into compliance with regulation.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)
  • Bond (updated)
  • LIC610D Emergency Disaster Plan (updated)
  • LIC308 Designation of Responsible Party

continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2024 03:48 PM - It Cannot Be Edited


Created By: Julie Florio On 12/12/2024 at 03:01 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 HOMES, LLC
FACILITY NUMBER: 486804077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ensuring that all cleaning products, chemicals and other potentially dangerous items were inaccessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Licensee immediately removed items and secured storage cabinets with locks to ensure that all dangerous items are inaccessible to residents in care. POC cleared during todays inspection.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/12/2024 03:48 PM - It Cannot Be Edited


Created By: Julie Florio On 12/12/2024 at 03:01 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 HOMES, LLC
FACILITY NUMBER: 486804077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring that centrally stored medication records for each resident were maintained in compliance with regulation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Licensee to submit proof of staff training on proper documentation and record keeping of residents' centrally stored medication records, to include prescription start dates, prescription numbers, and prescription instruction, to CCL by POC due date 1/10/2025.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AMANI HOMES, LLC
FACILITY NUMBER: 486804077
VISIT DATE: 12/12/2024
NARRATIVE
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continued from LIC809C...

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal rights were given. Exit interview conducted with Administrator whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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