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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803944
Report Date: 06/06/2024
Date Signed: 06/06/2024 01:25:14 PM

Document Has Been Signed on 06/06/2024 01:25 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/
DIRECTOR:		NGATA, STEPHENFACILITY TYPE:
737
ADDRESS:3610 WALLACE ROADTELEPHONE:
(707) 536-9483
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 3CENSUS: 3DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Administrator, Stephen NgataTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Stephen Ngata. Fees are current. Contact information was reviewed.

LPA/Administrator initiated a tour of the facility around 10:30 am 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 105.9 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. Fire extinguisher are serviced and charged within the last year. Facility recently had an inspection from the local fire department who were not able to test the fire sprinklers system on 1/3/24 due to clients behaviors. However, combination carbon monoxide/smoke detectors were found operational. Most recent disaster drill conducted 5/11/24. Medications and their records were reviewed.
LPA initiated file review at 11:00 am. Three staff files and three client files were reviewed. Administrator was unable to provide two out of three client's (C1 & C2) medical assessment. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Stephen Ngata 6029263735 expires 8/23/2024. Client cash resources and documentation was reviewed. Facility general ledgers are not maintained accurate with cash on hand for all clients in care.

Administrator agreed to submit updates of the following documents by 6/28/2024: LIC 500 Personnel Summary, LIC308 Designation of Responsibility, LIC 400 Cash affidavit, surety bond & control of property.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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Document Has Been Signed on 06/06/2024 01:25 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 06/06/2024 at 01:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: UTULIVU HOME
FACILITY NUMBER: 496803944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in two out of three clients cash resources do not match cash on hand and general ledgers, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Administrator agreed to review all client's cash resources and will submit a self-certification form LIC9098 to CCL by POC due date.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in two out of three clients do not have medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Administrator agreed to obtain a current medical assessments and will submit a self-certification form LIC9098 to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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