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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803877
Report Date: 04/09/2024
Date Signed: 04/09/2024 12:06:27 PM

Document Has Been Signed on 04/09/2024 12:06 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/
DIRECTOR:
PERALTA, HANNAHFACILITY TYPE:
735
ADDRESS:810 EUCALYPTUS AVETELEPHONE:
(415) 408-3913
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Facility Manager, Allan JivioTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:15AM to conduct an Annual Required inspection and was greeted by Facility Manager. LPA and Facility Manager discussed the purpose of the visit. Administrator, Hannah Peralta was available by phone.

LPA and Facility Manager initiated a tour of the facility around 09:45 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 117 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the garage. Personal Protective Equipment is stored in the garage.


Fire extinguishers were last serviced December 12, 2023. Facility has combination smoke and carbon monoxide detectors located throughout the facility that were tested and operational during inspection. Most recent fire/disaster drill was conducted 04/05/2024. Client cash resources were reviewed. 3 of 4 clients had a negative balance.

Five staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Administrator, Hannah Peralta (6038008735) is up to date and expires 07/17/2024.

Continued on LIC809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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: 04/09/2024
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Continued from LIC809

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to Facility Manager. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 05/09/2024:

LIC 500 Personnel Report

LIC 9020 Resident Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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