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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804202
Report Date: 01/23/2024
Date Signed: 01/23/2024 12:47:40 PM

Document Has Been Signed on 01/23/2024 12:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ULINZI HOMEFACILITY NUMBER:
496804202
ADMINISTRATOR:KIHARA, EDDAHFACILITY TYPE:
735
ADDRESS:937 EMILY AVE.TELEPHONE:
(707) 293-8557
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 4CENSUS: 0DATE:
01/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Eddah Kihara-ApplicantTIME COMPLETED:
01:00 PM
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Licensing Program Analyst(LPA) arrived to conduct a Pre-Licensing Inspection and was greeted by Applicant, Eddah Kihara. Eddah Kihara will be the facility's Administrator.

Component III orientation was completed today, 1/23, with applicant, Eddah Kihara.

Facility has received a fire clearance approval from the local fire department- effective 10/3/23, for four (4) ambulatory clients.. Fire extinguishers, three (3) were serviced, and tagged, as required. Facility has smoke alarms and a carbon monoxide detector as required. Each client room had a working carbon monoxide detector. Facility has a required infection control plan. Facility has required emergency disaster plan.

LPA conducted a walk through of the home that will serve four clients once licensed. LPA observed the following: There was a small supply of perishable and nonperishable food. LPA discussed regulation regarding food service with applicant. There was an emergency food supply, including water in case of a disaster and/or facility emergency. Facility had a first aid kit, including the first aid guide book.

Hot water temperature was checked at 116.6 degrees Fahrenheit. Facility has a backyard that includes a patio table with an umbrella and chairs. Facility has sufficient supply of dishes, and cook ware to accommodate each client. Medications will be stored in a locked medication cart. Toxins/cleaners will be stored in locked cabinets located in the garage, and locked cabinets in the home. Applicant will be using their own vehicle to transport clients at this time. Applicant's vehicle has current car insurance; Applicant has a first aid kit for the vehicle.

Continued on LIC809C....
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ULINZI HOME
FACILITY NUMBER: 496804202
VISIT DATE: 01/23/2024
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Each private client room was furnished with most of the required items per regulation; Each client room needs a light/lamp that gives sufficient lighting for the client's use. The facility carpet has a large paint spill stain in the living room, and in other areas around the home, applicant stated they are getting the paint out of the carpet, and will have it done by LPA's next visit. LPA observed a large chair and ottoman that was dirty and needed cleaning, outside in the front door area of the facility. The front door area cement flooring needed cleaning and sweeping of dirt and items.

There was a large wooden board behind the chair which stuck out that can be a hazard to clients in care, applicant stated the board would be moved out and stored away. The front window above the outside chair/ottoman had a large crack in it. The backyard had a large stump that could be a safety hazard, the applicant stated they were having the stump removed. LPA observed the yard needing to be cleaned up and organized, and there were missing wooden slats in the cement patio that need repair so the patio is not a safety hazard for future clients in care. Applicant stated there are items being removed from the property, such as the stump, gas grill, and a refrigerator, etc.

The large kitchen windows, and two glass patio doors in the adjoining family room, had no window curtains/blinds/shades to use as needed for clients accessing these rooms. LPA observed the sun very bright in these rooms and in some areas the sun was blinding, making it hard to see. Applicant stated they were getting curtains for the windows and the patio doors in these two common areas, for the residents use and comfort. There was also wires from an old phone line sticking out of the wall in the dining room. Applicant will ensure these wires have the cover replaced and/or the wires are removed. LPA obtained pictures of items discussed during the inspection.

The applicant will notify the LPA when the above items are repaired, replaced, removed, installed and/or completed; The LPA will return to conduct a second inspection. Applicant stated their understanding of the above.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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