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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803986
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:32:08 PM

Document Has Been Signed on 11/28/2023 03:32 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:SUMMERFIELD HOME CAREFACILITY NUMBER:
496803986
ADMINISTRATOR:WAINAINA, KENNEDYFACILITY TYPE:
740
ADDRESS:2725 SUMMERFIELD RD.TELEPHONE:
(415) 408-1603
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 5DATE:
11/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator, Kennedy WainainaTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to continue the required Annual inspection and was greeted by Kennedy Wainaina, Administrator. Facility currently has five (5) residents in care none of which are currently on hospice.

At approximately 12:50pm LPA and Administrator spoke about annual fee being past due. LPA gave Administrator copy of LIS pin # and print out of fee chart with late fee assessed as of 11/23/2023. LPA advised Administrator non-payment could result in a citation. Administrator immediately paid online and LPA observed payment confirmation.

LPA reviewed Guardian employee roster with Administrator and verified all current employees are associated and have fingerprint clearance.

At approximately 1:00pm LPA reviewed 5 of 5 resident files.

At approximately 2:00pm LPA reviewed 5 of 5 staff files, excluding Administrator files. At approximately 3:00pm LPA and Administrator did a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the kitchen.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Exit interview conducted with Administrator and a copy of this report was given.

No deficiencies cited during this inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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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