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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803537
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:08:33 AM

Document Has Been Signed on 07/26/2022 10:08 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:KENWOOD GREENSFACILITY NUMBER:
496803537
ADMINISTRATOR:VEGVARY, JULIUSFACILITY TYPE:
740
ADDRESS:340 GREENE STREETTELEPHONE:
(707) 483-0998
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY: 8CENSUS: 6DATE:
07/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Maria CinocoTIME COMPLETED:
10:00 AM
NARRATIVE
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During the course of a complaint investigation, LPA noted that the laundry room was not locked and that hazardous materials were accessible to residents. LPA brought this to the attention of the caregiver who secured the room and the materials.


The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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 07/26/2022 10:08 AM - It Cannot Be Edited


Created By: David Leibert On 07/26/2022 at 09:25 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: KENWOOD GREENS
FACILITY NUMBER: 496803537

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited
CCR
87309(a)

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87309(a) STORAGE SPACE. 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. Based upon observations, this requirement has not been met as evidenced by: During the course of complaint investigation, LPA
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Administration shall provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL by POC date in order to clear the deficiency.
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observed laundry room containing window cleaner, detergent, and cleanser on counter and in unlocked cabinet while six residents were present in facility. This posed an immediate risk to their safety.
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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:Carla Martinez
LICENSING EVALUATOR NAME:David Leibert
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


LIC809 (FAS) - (06/04)
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