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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803944
Report Date: 09/17/2021
Date Signed: 09/17/2021 11:58:19 AM

Document Has Been Signed on 09/17/2021 11:58 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:UTULIVU HOMEFACILITY NUMBER:
496803944
ADMINISTRATOR:NGATA, STEPHENFACILITY TYPE:
737
ADDRESS:3610 WALLACE ROADTELEPHONE:
(707) 665-5705
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 3CENSUS: 2DATE:
09/17/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Lead Staff, Nayeli JimenezTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct a Post Licensing inspection and met with Lead Staff, Nayeli Jimenez. Administrator, Stephen Ngata was unavailable during inspection. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was asked to sign in and was screened for temperature. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout the facility. Per staff, they regularly discuss infection control with clients. Staff are required to wear masks while in the facility. Observed staff had masks on during this visit. Staff are screened before each shift for Covid-19 symptoms and clients are screened each day. Temperatures are documented.

LPA and staff discussed client activities and visitation. Facility has a designated visitation area indoors and outdoors. Facility is following PIN 21-40-ASC regarding visitation, testing and vaccination certification for visitors.

Caregivers have completed PPE training but have not been N-95 Fit tested. Commonly touched surfaces are disinfected twice per shift.

Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is located in an area that is accessible to staff who need it. Facility maintains a 30 day supply of medication.

Staff and LPA discussed their Emergency Disaster Plan.



No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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