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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804202
Report Date: 02/24/2025
Date Signed: 02/24/2025 03:06:25 PM

Document Has Been Signed on 02/24/2025 03:06 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:ULINZI HOMEFACILITY NUMBER:
496804202
ADMINISTRATOR/
DIRECTOR:		KIHARA, EDDAHFACILITY TYPE:
735
ADDRESS:937 EMILY AVE.TELEPHONE:
(707) 293-8557
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 4CENSUS: 4DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Eddah Khara-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Alviso and Contreras, conducted a Required - 1 Year inspection, on 2/24/25 at approximately 9:20am, and met with Administrator Eddah Khara. All residents were at day program and/or their jobs during the inspection.

Facility has received a fire clearance approval for four (4) ambulatory clients. Fire extinguishers were observed to be charged as required. Facility has smoke alarms and a carbon monoxide detector as required. Facility has a required infection control plan. Facility has required emergency disaster plan.

LPAs reviewed four resident files, medication records/storage of medications, and P&I resident cash resources/records of P&I cash. P&I monies were maintained as required, and was observed to not mixed with facility funds and/or any other funds.

LPAs reviewed four (4) staff files. All staff had required criminal record clearance. Three staff had required first aid certification.

LPA toured the facility with the Administrator. Bathrooms were clean, had shower mats for residents use. Had required furnishings. There is a medication cart that was observed to be locked. Cleaners/disinfectants were locked in a storage cabinet in the garage. The facility was observed to be at a comfortable temperature. The backyard was toured and the fire exit gate opened properly during the inspection. Hot water was checked at 109.4 degrees Fahrenheit, which is within regulation.

The following forms are to be submitted by 3/24/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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 7
Document Has Been Signed on 02/24/2025 03:06 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/24/2025 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ULINZI HOME
FACILITY NUMBER: 496804202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Per file reviews, staff S3 lacked proof of required first aid training. the licensee did not comply with the section cited above in [1] out of [4] staff] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee to ensure that staff S3 obtains first aid certification; Until staff S# has first aid certification they may not be on shift by themselves. Submit proof of S3's first aid certification by 2/25/25. POC due 2/25/25.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed a 2.5 mcg inhaler in resident’s R1’s room on the window sill. The Administrator stated there is no order for this inhaler from the Physician. R1 does not handle their own medications, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee to ensure all medications, including any over the counter medications have Dr's Orders and are centrally stored as required. Obtain a Dr's Order for the medication and/or remove the medication from the facility if the Physician does not give an order for the medication. Submit plan of correction, POC, by 2/25/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/24/2025 03:06 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/24/2025 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ULINZI HOME
FACILITY NUMBER: 496804202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Staff S2 & S3 lacked a required health screening, LIC503, per file review. the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee to ensure that S2 & S3 obtain the required health screening report. Submit copies by POC due date of 3/14/25.
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per file review, staff, S2, S3, and S4, lacked sufficient proof of required training per regulations, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee to ensure all staff have required training per regulations, and submit proof of training by POC due date of 3/14/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/24/2025 03:06 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/24/2025 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ULINZI HOME
FACILITY NUMBER: 496804202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(4)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.

This requirement is not met as evidenced by:
Deficient Practice Statement
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er file review, staff, S2, S3, and S4, lacked sufficient proof of required medication training, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee to ensure all staff obtain required medication training. Submit proof of medication training by 3/3/2025.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed the food supply was not sufficient regarding non-perishable food items, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee stated they are going to purchase food supply today; Licensee will submit photos, and copy of food purchase receipt by 2/25/25. POC due 2/25/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/24/2025 03:06 PM - It Cannot Be Edited


Created By: Dina Alviso On 02/24/2025 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ULINZI HOME
FACILITY NUMBER: 496804202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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er file reviews staff, S2 S3 and S4 had no proof of emergency disaster plan training, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee to ensure that all staff obtain emergency disaster plan training, this is required from time of hire and annually thereafter. Submit proof of staff training having been completed. POC due 3/14/25.
Type B
Section Cited
CCR
85077(b)
85077(b) Personal Services -Licensees shall provide basic laundry services, including washing and drying of clients' personal clothing, see LIC809D.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed no detergent for residents to do laundry and/or staff to do the laundry, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Licensee to ensure there is a supply of detergent to wash resident clothing items, linens, and any other items as wanted and/or needed. Submit photo and receipt of purchase of detergent for the facility to launder items as required/needed. POC due 2/24/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


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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: ULINZI HOME
FACILITY NUMBER: 496804202
VISIT DATE: 02/24/2025
NARRATIVE
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Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Surety bond
Resident Roster
Copy of current Administrator Certificate (when received)

The following deficiencies were observed:

LPAs observed a 2.5 mcg inhaler in resident’s R1’s room on the window sill. The Administrator stated there is no order for this inhaler from the Physician. Deficiency will be cited, Health Related Services 80075(k)(1)-The following requirements shall apply to medications which are centrally stored: Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D.



Per file reviews staff, S2 S3 and S4 had no proof of emergency disaster plan training. Deficiency will be cited, HSC1565(b) Other Provisions-Emergency Disaster Plan-If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster, see LIC809D


Staff S2 & S3 lacked a required health screening, LIC503, per file review. Deficiency will be cited, 80066(a)(10) A health screening as specified in Section 80065(g) is required for staff, see LIC809D.

Per file review, staff, S2, S3, and S4, lacked sufficient proof of required training per regulations. This deficiency will be cited, Personnel Requirements 80065 (f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance, see LIC809D.

Per file review, staff, S2, S3, and S4, lacked sufficient proof of required medication training. This deficiency will be cited, Personnel Requirements 80065 (f) (4) Assistance with prescribed medications which are self- administered, see LIC809D.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: ULINZI HOME
FACILITY NUMBER: 496804202
VISIT DATE: 02/24/2025
NARRATIVE
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Per file reviews, staff S3 lacked proof of required first aid training. This deficiency will be cited, 80075(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross, see LIC809D.

LPA observed no detergent for residents to do laundry and/or staff to do the laundry. This deficiency will be cited, 85077(b) Personal Services -Licensees shall provide basic laundry services, including washing and drying of clients' personal clothing, see LIC809D.

LPAs observed the food supply was not sufficient regarding non-perishable food items. LPA discussed food supply regulations with the Administrator. This deficiency will be cited, Food Service 85076(d)(1) -Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22,
Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with the Administrator Eddah Kihara.
Appeal rights provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
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