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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603875
Report Date: 01/09/2023
Date Signed: 01/09/2023 03:14:40 PM

Document Has Been Signed on 01/09/2023 03:14 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:UTOPIA PLACEFACILITY NUMBER:
374603875
ADMINISTRATOR:HAVERLY, CHRISFACILITY TYPE:
735
ADDRESS:14025 POWERS RDTELEPHONE:
(619) 227-7082
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 4CENSUS: 3DATE:
01/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:House Manager Vanessa WidmanTIME COMPLETED:
03:20 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) Kayla Hilario conducted an unannounced Case Management visit. LPA was allowed entry by, met with, and discussed the purpose of the visit with House Manager Vanessa Widman. All staff present have current criminal record clearance.

Today's visit is in response to the self-reported death of Client 1 (C1 - See LIC811 Confidential Names List). The date of death is listed as 01/05/2023, and C1 passed away at the hospital on 01/05/2023.

LPA obtained additional information and records on this date. LPA also toured the facility both inside and outside. All clients observed appeared appropriate for the facility. No immediate health or safety issues were identified.

No deficiencies were cited or observed on this date.

An exit interview was conducted with House Manager Vanessa Widman. A copy of this report and appeal rights (LIC 9058 03/22) were provided via hardcopy at the conclusion of the visit.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2023
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