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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803820
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:43:49 PM

Document Has Been Signed on 09/12/2024 04:43 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:ENSO VILLAGE, A KENDAL AFFILIATEFACILITY NUMBER:
496803820
ADMINISTRATOR/
DIRECTOR:		TAMMY MORATTOFACILITY TYPE:
741
ADDRESS:1801 BOXHEART DRIVETELEPHONE:
(925) 366-3414
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY: 222CENSUS: 180DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Annet Nakiyuka, interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:58 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and met with Annet Nakiyuka, Administrator.

At approximately 9:45am LPA spoke with Doug Helman, Interim CEO, via telephone to inquire as to the status of the facility's current Administrator of record, Tammy Morrato. CEO explained that Tammy Morrato was only ever intended as an interim Administrator until a permanent replacement was hired. LPA advised that the facility must give CCL at least 30 day notice whenever there is a change in Administrators. LPA advised that the required documents to process and approve the change of Administrator have not been received for Annet Nakiyuka, nor has CCL received notification that a change in Administrator was planned. Interim CEO will send required to documents to CCL as soon as possible.

At approximately 11:00am LPA and Admin toured the physical plant. The facility was found to be clean and at a comfortable temperature. Facility has two kitchens; one main kitchen currently utilized. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. All open food items and bin pantry items were labeled with contents and date of opening. Food was found to be of quality and a wide variety of fresh fruits and vegetables were readily available. Kitchen was clean, well organized, and LPA observed kitchen staff adhering to safety and sanitation best practices. Kitchen cleaning supplies and toxins are stored away from any food storage or preparation areas. Water temperature measured at 130 degree F; caution/warning signs were present at each sink. LPA, Admin, and kitchen lead discussed adding verbiage indicating water temperature is over 125 degrees F.

Fire extinguishers were last inspected 9/25/2023. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and last serviced by Johnson Controls Fire Protection on 12/1/2023.

At approximately 2:30pm LPA conducted review of six [6] staff records. All required documentation present.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 2
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: ENSO VILLAGE, A KENDAL AFFILIATE
FACILITY NUMBER: 496803820
VISIT DATE: 09/12/2024
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Continued from 809...

In addition to annual inspection of the physical plant, LPA also conducted inspection of Assisted Living units, part of facility's "Phase 3B" expansion. On 8/22/2024, fire clearance was granted for increased capacity of 376 non-ambulatory residents, an increase from 222 residents to now include Assisted Living. The fire clearance for the increased capacity does not include any Memory Care units and is not applicable to Memory Care. Assisted Living units are located on level 2 of Building I in sections H and I. Kitchen for Assisted Living accessible only by key card, which includes access to sink and range/oven. Water temperature in sinks accessible to residents in care measured at 117.5 degrees F in room I272, 114.4 degrees F in room H262, and 112.7 degrees F in room H267, which are all within the allowable range of 105 to 120 degrees F.

Per CCL inspection completed 3/6/2024, prior to Assisted Living and Memory Care being approved, Administrator was to provide a written plan indicating how potential areas of risk including, but not limited to, fountains, bioswales, heaters, car garage, and compacter will remain safe for residents in care. As of today, CCL has not received any such plan. Therefore, prior to any Assisted Living residents moving in, Administrator must provide a written plan indicating how potential areas of risk including, but not limited to, fountains, bioswales, heaters, car garage, trash compacter, and pool now in operation will remain safe for residents in care. Written plan to be approved by CCL before any occupancy of Assisted Living units.

Annet Nakiyuka Administrator Certificate 6061965740 expired 4/11/2024. LPA verified Administrator renewal certificate application has been received and new Admin certificate number will be 7027319740. All fees are current as of this time.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC308- Designation of Responsibility,
Liability Insurance declarations page.

Exit interview conducted with Admin. No deficiencies cited.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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