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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804307
Report Date: 01/15/2026
Date Signed: 01/15/2026 01:17:17 PM

Document Has Been Signed on 01/15/2026 01:17 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: DATE:
01/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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At approximately 8:35 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to conducted a required annual inspection and met with caregiver Azieb Tecle who has Designation of Responsibility (RP) who called licensee/administrator Abraham Naizgy who was away working at his second job as a nurse.

Facility was formerly located in Antioch, Ca. and is currently licensed for six (6) ambulatory residents four (4) upstairs bedrooms. All required rooms have a smoke alarms. Licensee has both an Emergency Disaster Plan and Infection control plan on file.

At approximately 9:05 AM LPA conducted a tour and found the facility to be clean, without odors, food in freezers and pantries were found to be stored within compliance. All exits were clear of obstruction. All resident rooms had required accommodations per regulations. All resident rooms, common areas, bathrooms, and hallways had sufficient lighting for client use. Hot water was checked at 119.9F degrees Fahrenheit. There were two fire extinguishers purchased 11/13/2025 and found fully charged, licensee was advised to tape purchase reciepts or have fire extinguishers inspected annually and tagged. 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. An exterior shed was found to be locked and have a few hardware supplies.

Licensee was advised to ensure that community bathrooms do not have cloth wash cloths to reduce infection risk.
Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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 8
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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Document Has Been Signed on 01/15/2026 01:17 PM - It Cannot Be Edited


Created By: Star Stevenson On 01/15/2026 at 12:10 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: NAIZGHIS ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 496804307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with licensee and staff the licensee did not comply with the section cited above in three (3) out of four (4) personnel records 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 to self-certify by writing that they have read regulation 80066 and it's sub-sections, as well as provide proof of S1, S2, S3 and S4 have Tuberculosis testing with results, as well as the results of a Physicians Health Physical for S2 and S4
Type B
Section Cited
CCR
80066(a)(12)(B)
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: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with licensee and S1, the licensee did not comply with the section cited above one (1) out of four (4) personal records 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 to self-certify that they have read Regulation 80066(a)(12)(B) and to report to Community Care Licensing the results of S1's background/criminal clearance by Guardian or other source.
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:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/15/2026 01:17 PM - It Cannot Be Edited


Created By: Star Stevenson On 01/15/2026 at 12:10 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: NAIZGHIS ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 496804307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview the licensee did not comply with the section cited above in two(2) out of three (3) client records 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 to self-certify in writing that they have read regulations in 80070 and submit to Community Care Licensing Physicians Medical Assessments, as well as, the results of Tuberculosis testing for C1 and C2.
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:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
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: NAIZGHIS ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 496804307
VISIT DATE: 01/15/2026
NARRATIVE
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Continued from LIC809

Facility updated it's Emergency Disaster Plan on 01/09/2026

At 10:30 AM LPA evaluated four(4) staff records and found S1, S2, S3 and S4 to have no evidence of TB testing and S1, S2, and S4 without evidence of an MD health physical and a Type B citation issued for violation of CCR 80066(a) In addition S1 was found to not be criminally cleared to work or associated on Guardian having begun work on10/12/2025 and a Type B citation was issued for violation CCR 80066(a)(12)(B)

At 12:00 PM LPA evaluated three (3) of three (3) client records and found both C1 and C2 have no Medical Assessment or results of Tuberculosis testing and a Type B citation was issued for violation of CCR 80070(a)

Licensee was advised to ensure that toxins (detergents and bug sprays) in both the laundry room and garage are locked at all times and that an emergency evacuation chair by mounted that the top of the stairs in case of emergency.

Facility does not handle client P&I money. Medicines were found to be centrally stored and locked as required by regulation.

Licensee to provide to Community Care Licensing the following documents to update the facility file by 02/10/2025 including:
1)LIC308 Designation(s) of Facility Responsibility
2)LIC500 Personel Roster Report
3)LIC9020 Registration of Facility Clients
4)Updated LIC610D Emergency Disaster Plan.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Azieb Tecle and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
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