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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803944
Report Date: 05/09/2023
Date Signed: 05/09/2023 05:09:10 PM

Document Has Been Signed on 05/09/2023 05:09 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
SANTA ROSA RO, 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:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Administrator, Stephen NgataTIME COMPLETED:
05:18 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Stephen Ngata.

LPA initiated a tour of the facility around 2:00 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in bathroom used by clients measured at 106 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies are inaccessible to clients in care. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility has emergency food and water supplies. LPA observed two arches in the backyard that are starting to rot and are not safe to walk under. Administrator agreed to ensure that clients do not go near the arches until they can be replaced or repaired.

Fire extinguisher are charged but have not been serviced within the last year. Facility recently had an inspection from the local fire department who tested the fire system. No issues with the combination carbon monoxide/smoke detectors were noted, however the fire department directed facility to have their fire system vendor conduct an annual servicing. Most recent disaster drill was conducted April 2023.

Four staff files and three client files were reviewed. Administrator was unable to find the Medical Assessment and Functional Capabilities Assessment required upon move-in. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Stephen Ngata 6029263735 expires 8/23/2024. Medications and medication records were reviewed. Client cash resources and documentation was also reviewed.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: UTULIVU HOME
FACILITY NUMBER: 496803944
VISIT DATE: 05/09/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 6/09/2023:


LIC 500 Personnel Summary
LIC308 Designation of Responsibility (If applicable)
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

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

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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