<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803944
Report Date: 05/29/2025
Date Signed: 05/29/2025 03:17:38 PM

Document Has Been Signed on 05/29/2025 03:17 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/
DIRECTOR:		JIMENEZ, NAYELYFACILITY TYPE:
737
ADDRESS:3610 WALLACE ROADTELEPHONE:
(707) 536-9483
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 3CENSUS: 3DATE:
05/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Nayley Jimenez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year inspection and was greeted by Administrator Nayley Jimenez. Utulivu Home is Licensed as an Adult Residential Facility - Enhanced Behavioral Supports Home (ARF-EBSH). The facility is a single story ranch house with a large back yard and garden area. There is a new, separate, single room building that serves as a Sensory Room. The newly added Sensory Room building has not been added to the facility drawings and submitted to Community Care Licensing (CCL). A Technical Violation is being issued for the drawings not having been submitted. The facility has an approved fire clearance for three (3) non-ambulatory Clients between the ages of eighteen (18) and fifty-nine (59). Upon arrival, LPA was informed that there were three (3) clients in care. At approximately 8:55 AM, LPA reviewed the Facility's Staff Roster and observed that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:45 AM, LPA toured the facility with Administrator Jimenez. All exits were clear and unobstructed. The facility's two (2) fire extinguishers were charged but they did not have last serviced tags attached to them. A Technical Violation is being issued for the extinguishers not having an annual inspection. The facility was sufficiently lighted. LPA inspected three (3) client bedrooms and observed all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored inaccessible to clients. Facility has an infection control plan as required. The facility has a required emergency disaster plan.

Continued on 809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
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: 05/29/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...Continued from 809

The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted in 5/2025. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were observed to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

At approximately 10:45 AM, LPA reviewed three (3) client files. Three (3) of three (3) client files were observed to not have LIC 613 Personal Rights documents. This deficiency will be cited. All other required documentation was observed in their files. LPA reviewed three (3) staff files. Staff member S1 was observed not to have tuberculosis (TB) test results in their file. Staff member S2 was observed not to have an LIC 503 Health screening or TB test results in their file. Staff member S3 was observed not to have an LIC 503 Health screening in their file. These deficiencies will be cited. All other required documentation including First Aid and CPR certification and proper training documentation were observed in the staff files. LPA spot checked Medication for two (2) clients. LPA observed all medications to be centrally stored, secure and with proper documentation. Client’s monies for personal and incidental items (P&I) were spot checked and observed to be secure and to match P&I logs.

Nayely Jimenez's Administrator Certification 7032215715 is current with an expiration date of 12/13/2025.

LPA requested the following documents be submitted to Community Care Licensing by 6/27/2025:

LIC 500 Personnel Report


LIC 308 Designation of Responsibility
LIC 610E Emergency Disaster Plan
Updated Facility Sketch

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names, 9102 Technical Violations and Appeal Rights discussed and provided to Administrator Jimenez. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/29/2025 03:17 PM - It Cannot Be Edited


Created By: Robert Frank On 05/29/2025 at 02:37 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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that staff members S2 and S3 did not have an LIC 503 Health Screen in their personal file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
1
2
3
4
Licensee or Administrator will submit to Community Care Licensing completed LIC 503 Health Screens for staff members S2 and S3 by POC due date of 6/26/2025.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that staff members S1 and S2 did not have Tuberculosis test documents in their personal file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
1
2
3
4
Licensee or Administrator will submit to Community Care Licensing Tuberculosis test documents for staff members S2 and S1 by POC due date of 6/26/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/29/2025 03:17 PM - It Cannot Be Edited


Created By: Robert Frank On 05/29/2025 at 02:49 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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(d)
80072 Personal Rights
(d)At admission, a client and the client's authorized representative shall be personally advised of and given a list of the rights specified in Sections 80072(a)(1) through (10) and in the applicable Personal Rights sections of chapters 2 through 7.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that Clients C1, C2 and C3 did not have LIC 613 Personal Rights forms in their personal files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
1
2
3
4
Licensee or Administrator will provide signed 613 Personal Rights forms for clients C1, C2 and C3 to Community Care Licensing by POC due date of 6/26/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6