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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803820
Report Date: 03/04/2025
Date Signed: 03/04/2025 03:45:43 PM

Document Has Been Signed on 03/04/2025 03:45 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: 376CENSUS: 8DATE:
03/04/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:41 AM
MET WITH:Annet Nakiyuka, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management inspection and met with Annet Nakiyuka, Administrator (Admin).

LPA and Admin conducted a tour of Memory Care (MC) units, part of facility's "Phase 3C" expansion. On 2/25/2025, fire clearance was granted for increased capacity of 400 non-ambulatory residents, an increase from 376 residents to now include Memory Care. Memory Care units are located on Level 1 of the Main Building in sections H and I.

Facility has a MC lobby waiting area in which the entrance door to the MC unit is located. Currently, the door does not latch and is not working as a delayed egress door. LPA and Admin spoke with Darcy Wallace, Director of Facilities (DOF). He explained that the door is being repaired and will have a magnetic function added to it such that it will latch properly and function as a delayed egress door from both sides. He also indicated that they identified a faulty wire related to the functionality of the door that is also being repaired/replaced.

Kitchen for MC unit includes access to refrigerator, sink, and range/oven. LPA noticed locking mechanism on the refrigerator. Admin explained that it will be removed and was only there temporarily. LPA and Admin tried to get a hot water temperature reading from the kitchen sink but could not get any hot water to dispense. Bathroom sinks in the kitchen bathrooms also do not dispense hot water and only dispense water when the motion sensor is activated and a hand (or solid object) is maintained in front of the sensor. LPA and Admin discussed this functionality to potentially be problematic for MC residents to use. Admin will look for an alternative option and report back to LPA. Range/stove top of oven in MC kitchen has a locking feature. A key must be inserted into the lock on the wall to in order for the knobs on the oven to function properly and turn on the heating elements. LPA and Admin discussed adding a barrier of some kind that will prevent MC

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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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 3
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: 03/04/2025
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residents from accessing the hot stove top after it has been in use. Admin will look for an option and report back to LPA. Kitchen has a storage closet and laundry room, LPA and Admin discussed ensuring these doors are locked at all times, including the laundry room. Laundry room does have a storage cabinet with locking function for detergents and toxins.

LPA and Admin toured MC resident units I166, I175, H164, and H156. All units have windows that open a maximum of 3-4 inches. Bathrooms all have grab bars, but each unit will need a slip-resistant mat, strips, or flooring in all bathtub and shower floors. All slip-resistant mats, strips, or flooring shall be in good repair and maintain slip-resistant properties. All bedrooms and bathrooms have pull cords. Water temperature in sinks accessible to residents measured at 114.5 degrees F in room I166, and 105.5 degrees F in room H164, which are both within the allowable range of 105 to 120 degrees F.

MC unit common area has a device that looks like a fireplace but is actually a Water Vapor Electric Fireplace that runs on tap water. It is not hot to the touch and does not get hot while in operation.

MC unit has fire extinguisher cabinets on the walls that are locked with padlocks. LPA asked Admin about the padlocks, Admin advised this is allowed per the fire marshal. Admin explained facility wants to padlock them for safety reasons. Admin showed and forwarded to LPA email from fire marshal allowing the padlocks to be present. Emailed states, per California Fire Code (CFC) 906.8 Cabinets: "Cabinets used to house portable fire extinguishers shall not be locked. Exceptions: in group I-3 occupancies and in mental health group I-2 occupancies, access to portable fire extinguishers shall be permitted ot be locked or to be located in staff locations provided that staff has the keys." Group I-2 occupancy is a classification for buildings that provide medical care to more than five [5] people who are unable to care for themselves. Supervised living facilities are categorized as group I-2.

While touring the MC unit, LPA and Admin identified three [3] areas that may present as problematic in regards to elopement: The north-facing Dovetail door (with identification placard labeled Guest Lobby at Boxheart Dr), Building H stairwell exit, and Building I stairwell exit. Each of these exits open up to a

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

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ENSO VILLAGE, A KENDAL AFFILIATE
FACILITY NUMBER: 496803820
VISIT DATE: 03/04/2025
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non-secured area of the facility. The Building I stairwell exit opens up to a high-traffic area of the facility where the trash compactor, trash bins, the parking garage, and generators are located. Admin discussed with LPA her ideas of adding a perimeter fence along the paved areas immediately surrounding these exit doors. Admin will discuss options with DOF and report back to LPA.

Prior to the admission of Memory Care residents being approved, the facility will address/correct the following areas of concern:
  • Memory Care unit entrance door located in Memory Care lobby/waiting room to be repaired and delayed egress operational from both sides as well as faulty wire repaired/replaced.
  • Memory Care kitchen faucet to dispense hot water with temperatures measuring within regulation
  • Memory Care range/oven to have barrier in place making any hot elements inaccessible to residents in care
  • Memory Care refrigerator lock removed
  • Bathrooms in Memory Care kitchen to dispense hot water with faucet functionality such that Memory Care residents can use them without difficulty
  • Each Memory Care resident unit will need a slip-resistant mat, strips, or flooring in all bathtub and shower floors. All slip-resistant mats, strips, or flooring must be in good repair and maintain slip-resistant properties.
  • The three [3] exit areas: The north-facing Dovetail exit door, Building H stairwell exit door, and Building I stairwell exit doors to have a barrier preventing Memory Care residents from accessing non-secured area of the facility.

Admin will contact LPA once all items have been addressed/corrected. Addressed/corrected items to be approved by CCL before any occupancy of Memory Care units.

No deficiencies cited. Exit Interview conducted with Administrator.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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