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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803944
Report Date: 04/25/2022
Date Signed: 04/25/2022 12:59:36 PM

Document Has Been Signed on 04/25/2022 12:59 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:UTULIVU HOMEFACILITY NUMBER:
496803944
ADMINISTRATOR:NGATA, STEPHENFACILITY TYPE:
737
ADDRESS:3610 WALLACE ROADTELEPHONE:
(707) 536-9483
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 3CENSUS: 3DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Stephen NgataTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Administrator, Stephen Ngata. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by the administrator which included checking temperature and signing in. LPA confirmed that visitors are screened and vaccination verification is being conducted per Provider Information Notice (PIN) 22-07-ASC. LPA conducted a walk through of the facility and observed the following: Facility has COVID-19 posters throughout that included 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. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected four times per day. Facility maintains documentation of staff and client daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation indoors per CCL guidance. Staff have completed PPE training but have not yet been N95 fit tested. Per Administrator they frequently go over donning and doffing of PPE with staff and provided LPA with some training logs. LPA and Administrator discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers are not yet due for servicing. Hardwired smoke and carbon monoxide detectors were tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: UTULIVU HOME
FACILITY NUMBER: 496803944
VISIT DATE: 04/25/2022
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Continued from LIC809

Administrator and LPA discussed their Emergency Disaster Plan and the new Infection Control Plan that all facilities must submit to CCL by June 30, 2022.



Licensee/Administrator to submit updates of the following documents by 05/25/2022:
  • LIC 308 Designated Administrator
  • LIC 500 Personnel Summary
  • LIC 9020 Register of Facility Client’s/Resident’s

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

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC809 (FAS) - (06/04)
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