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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603875
Report Date: 02/08/2024
Date Signed: 02/08/2024 06:36:11 PM

Document Has Been Signed on 02/08/2024 06:36 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:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:26 PM
MET WITH:Direct Support Professional (DSP) Cale BlountTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct an annual licensing inspection. LPA identified herself to Direct Support Professional (DSP) Blount and was granted entry into the facility. House Manager (HM) Brenda Tafolla was contacted and arrived at the facility to assist LPA with the inspection. The facility is licensed to serve four (4) clients; of which 3 may be non-ambulatory. The facility is approved for delayed egress. During today's visit all three (3) clients were present.

An overall inspection of the facility began today however due to time constraints LPA was unable to complete the visit and will return at a later date to conduct the remaining portion of this inspection.



No deficiencies cited at today's visit. This report was discussed with House Manager Tafolla. A copy of the report and License Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of this report
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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