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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800791
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:05:09 PM

Document Has Been Signed on 01/16/2025 03:05 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:ZINA'S CARE HOME IIFACILITY NUMBER:
486800791
ADMINISTRATOR/
DIRECTOR:		ZINA LEEFACILITY TYPE:
735
ADDRESS:2112 ALLSTON PLACETELEPHONE:
(707) 432-1312
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Zina Lee, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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01/16/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 3 clients in care. Facility is currently in the process of remodeling the master bedroom and bathroom. Per conversation with Administrator, construction started 01/09/2025 and should be done by Sunday (01/19/2025).

At approximately 12:50pm, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 109.9 and 117.4 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 10/2024. Facility conducts fire drills with the last one being conducted 01/2025. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired. Sharps are kept in a locked drawer located in the kitchen. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 3 client records. 2 of 3 records had the required documentation. One client was missing their medical assessment/TB. Per conversation with Administrator Client 1 (C1) got a hold of their binder and ripped up paperwork. Administrator notified LPA, C1 has a doctors appointment later today (01/16/2025) and will be receiving an updated medical assessment/TB and needs and service plan. LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. However, Staff 1 (S1) was missing their medical assessment/tb. Per conversation with Administrator S1 has had their physical done and will get a copy to put in their file.

continued on LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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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: ZINA'S CARE HOME II
FACILITY NUMBER: 486800791
VISIT DATE: 01/16/2025
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No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/16/2025:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC400- Affidavit Regarding Client/Resident Cash Resources
LIC402- Surety Bond

Exit interview conducted with Staff Member and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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