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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804202
Report Date: 01/26/2026
Date Signed: 01/26/2026 05:01:57 PM

Document Has Been Signed on 01/26/2026 05:01 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:
01/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Eddah Kihara-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Alviso, conducted a Required - 1 Year inspection, on 1/26/2026 at approximately 9:20am, and met with Administrator Eddah Kihara. All residents were at day program and/or their jobs during the inspection.

Facility has a fire clearance approval for four (4) ambulatory clients. Fire extinguishers were observed to be charged and tagged as required. Facility has smoke alarms, and carbon monoxide detectors, as required. Facility has a required infection control plan. Facility has required emergency disaster plan. Per record review. last emergency disaster drill was on 12/15/25, a fire drill, and 9/9/25, an earthquake drill.

LPA reviewed four (4) resident files, medication records/storage of medications, resident cash resources (P&I funds),and client cash/financial maintenance records. All financial/client funds were observed to be in-tact, maintained as required, and not mixed with facility funds and/or petty cash funds.
LPA reviewed five (5) staff files. All staff had required criminal record clearance. All direct care staff have first aid certification, and CPR certification, as required. LPA reviewed staff training. Administrator certificate, for Eddah Kihara, is current, expires 9/20/2026.

LPA toured the facility with the Administrator. Facility was observed to be clean and orderly. Hot water was measured at 114.8 degrees Fahrenheit. All exits were free and clear of obstruction. Bathrooms were clean, and had shower mats for residents use. Facility has sufficient furnishings for resident use. There is a medication cart for storing all resident medications, including any refills; Medication cart was locked and inaccessible to residents, and those that are not trained to handle facility resident medications. Cleaners/disinfectants were locked in a storage cabinet in the garage. The facility was observed to be at a comfortable temperature. Facility had a sufficient supply of food. The backyard had a patio table and chairs for resident use; The patio set had a canopy tent that provides shade for the clients as needed. The backyard's fire exit gate was free and clear of any obstructions, and opened freely as required.
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 01/26/2026
NARRATIVE
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 The following forms are to be submitted by 2/26/26:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610D (9 pages)-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
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

The following deficiencies were observed:

LPA observed during the inspection check that three (3) smoke alarms were not working; One smoke alarm was located in resident room #3, second smoke alarm was in resident room #4, and the third smoke alarm was in the hallway by all resident bedrooms. All smoke alarms are to be working as needed/required, smoke alarms are part of the fire clearance inspection and fire clearance approval. This deficiency will be cited, 80020(a) Fire Clearance-All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal, see LIC809D.



Per LPA record reviews, Client C4 lacked a required medical assessment, including TB test & results. This deficiency will be cited, 80069(b) Client Medical Assessment- In ARFs prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment, see LIC809D.

Per LPA record reviews, Client C4 lacks Dr's Orders and/or a medication list signed by the Physician of the prescribed medications being provided to C4. This deficiency is being cited, 80069(c)(3) Client Medical Assessment- In ARFs prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. 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.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2026 05:01 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/26/2026 at 04:12 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: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed during the inspection check that three (3) smoke alarms were not working; One smoke alarm was located in resident room #3, second smoke alarm was in resident room #4, and the third smoke alarm was in the hallway by all resident bedrooms. All smoke alarms are to be working as needed/required, smoke alarms are part of the fire clearance inspection and fire clearance approval, 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: 01/27/2026
Plan of Correction
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Licensee/Administrator to ensure that the three identified smoke alrms, Room #3, room #4, and the hallway, are replaced and working appropriately to ensure fire clearance approval is maintained as required. Submit plan of correction, and written self certification that the smoke detectors were replaced as required by the correction plan. POC due 1/27/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2026 05:01 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/26/2026 at 04:16 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: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA record reviews, Client C4 lacked a required medical assessment, including TB test & results, 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: 02/12/2026
Plan of Correction
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Licensee/Administrator to obtain a medical assessment for client C4 as required. Submit copy of medical assessment to the Department once received, no later than 2/12/26. POC due 2/12/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2026 05:01 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/26/2026 at 04:34 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: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(c)(3)
80069(c)(3) Client Medical Assessment- The medical assessment shall include the following: Identification of any prescribed medications being taken by the client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA record reviews, Client C4 lacks Dr's Orders and/or a medication list signed by the Physician of the prescribed medications being provided to C4, 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: 01/27/2026
Plan of Correction
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Licensee/Administrator to obtain Dr's Orders, medication prescriptions signed by the Physician, for Client C4's medications. Licensee to ensure that all resident medications, including over-the -counter medications, have Dr's Orders as required by regulation. Follow-up by 1/30/26 with copies of the medication prescriptions for C4. POC due 1/27/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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