<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804307
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:35:18 PM

Document Has Been Signed on 01/09/2025 03:35 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:NAIZGHIS ADULT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
496804307
ADMINISTRATOR/
DIRECTOR:		NAIZGY, ABRAHAMFACILITY TYPE:
735
ADDRESS:2364 SANDI LNTELEPHONE:
(707) 696-3913
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 0DATE:
01/09/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Abraham Naizgy-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Alviso conducted a pre-licensing inspection, at approximately 2:00pm on 1/9/25, and met with Applicant/Administrator Abraham Naizgy. This application is a change of location.

LPA conducted a component III orientation with Applicant Abraham Naizgy, 1/9/25. Applicant has an approved fire clearance for six (6) ambulatory residents- effective 12/26/25. There is a carbon monoxide detector in the facility. All required rooms have a smoke alarm. There are three (3) resident rooms, all are shared rooms (two (2) residents to a room). Applicant has submitted a required emergency disaster plan, and a required infection control plan.

The LPA toured the facility with applicant Abraham Naizgy. All exits were clear of obstruction. The facility was clean and orderly. All resident rooms had required accommodations per regulations. All resident rooms, common areas, bathrooms, and hallways had sufficient lighting for residents use. Hot water was checked at 114.6 degrees Fahrenheit. There were three fire extinguishers purchased 12/26/24, per reviewed receipt. Carbon monoxide detectors, 2, worked properly during the inspection. All smoke alarms worked properly during the inspection; The smoke alarms are hard wired. Facility had a sufficient supply of perishable and non-perishable food items. LPA observed the backyard to be clean and orderly. There is a cabinet that will be used for centrally storing and locking up medications. There is a large storage cabinet (s) that locks and will be used for cleaners/disinfectants and any other items that may pose a risk to residents in care. All outside walkways/pathways were free and clear of obstruction as required.

Component orientation III was completed with applicant Abraham Naizgy, 1/9/25.

Pre-Licensing is complete and this facility has no apparent health hazards and/or concerns observed during this inspection. LPA will submit a copy of the report to the application unit; The application Analyst will notify the applicant of the application status.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 1