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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803877
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:06:29 PM

Document Has Been Signed on 02/03/2023 02:06 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:YUMI HOMEFACILITY NUMBER:
216803877
ADMINISTRATOR:PERALTA, HANNAHFACILITY TYPE:
735
ADDRESS:810 EUCALYPTUS AVETELEPHONE:
(415) 408-3913
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 4DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nurse, Alfredo FernandezTIME COMPLETED:
02:16 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by the On Duty Nurse, Alfredo Fernandez. Administrator, Hannah Peralta was available by phone. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by nurse and asked to sign in and complete a questionnaire with standard Covid-19 screening questions. LPA initiated a walk-through of the facility around 1:00pm and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected once per shift per maintained log. Facility continues to screen clients and staff for Covid-19 daily and maintain documentation.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Staff continue to receive training on infection control and Personal Protective Equipment (PPE). Staff have been N95 fit tested.

Facility has more than a 30 day supply of PPE including but not limited to masks, gloves, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced November 2022. Facility has a fire system that includes carbon monoxide detectors that is maintained by a vendor. The most recent testing and service was conducted November 2022.


Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: YUMI HOME
FACILITY NUMBER: 216803877
VISIT DATE: 02/03/2023
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Continued from LIC809

Facility has submitted their Infection Control Plan and Mitigation Plan.

Administrator to submit updates of the following documents by 03/03/2023:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
Updated Mitigation Plan (if changes)
Updated Infection Control Plan (if changes)
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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