374603875-4-5-2023-08-AS-ARAZ-CQLPRT-20230405113316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603875
Report Date: 04/05/2023
Date Signed: 04/05/2023 11:33:25 AM

Document Has Been Signed on 04/05/2023 11:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	UTOPIA PLACE		FACILITY NUMBER:	374603875
ADMINISTRATOR:	HAVERLY, CHRIS		FACILITY TYPE:	735
ADDRESS:	14025 POWERS RD		TELEPHONE:	(619) 227-7082
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY: 4		CENSUS:	DATE:	04/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Direct Support Staff Brenda Tafolla andf Marisol VegaZavala		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with direct support staff Marisol VegaZavala and Brenda Tafolla.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom three (3) may be non-ambulatory. During today’s inspection, there were a total of three (3) clients in care, and per medical records, two (2) were non-ambulatory and one (1) was ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA,, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, sinks and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 105 F, Bathroom #1 was 108 F and bathroom #2 was 107F.

Refrigerator and freezer temperatures were in compliance. Freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: UTOPIA PLACE	FACILITY NUMBER: 374603875
	VISIT DATE: 04/05/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water were observed on the premises. Per the staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff and clients and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with direct support staff Brenda Tafolla, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

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