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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176800965
Report Date: 03/01/2022
Date Signed: 03/01/2022 10:15:16 AM

Document Has Been Signed on 03/01/2022 10:15 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FERRIS HOMEFACILITY NUMBER:
176800965
ADMINISTRATOR:FITTS, JENNIFERFACILITY TYPE:
735
ADDRESS:15190 KONOCTI VIEWTELEPHONE:
7072957710
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 5CENSUS: 3DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer Fitts - LicenseeTIME COMPLETED:
10:15 AM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year Infection Control Inspection of the facility. LPA was welcomed by Licensee Jennifer Fitts. There are 3 clients enrolled in the program.

At approximately 9:15 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure in locked kitchen cabinet. There is a sufficient supply of hygiene products and linens on hand for client use. Hot water temperature measured 150.1 degrees F. within Title 22 acceptable regulation of 105 to 120 degrees F in client’s bathrooms. Fire extinguishers are fully charged and current. Carbon Monoxide detector was present. Disaster Drills are conducted twice yearly, with the last drill conducted 11/2021. Facility does not handle client monies.


Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 7/15/2021. Facility has PPE supply stored in office in kitchen cabinet. Licensee’s will be emailing booster vaccination cards this Friday 3/5/2022.



LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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: FERRIS HOME
FACILITY NUMBER: 176800965
VISIT DATE: 03/01/2022
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LPA was presented with proof of CPR & 1st Aid certification for staff.


No deficiencies cited during this visit in the areas inspected.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/15/2022 to RPRO:



Licensee’s will be emailing booster vaccination cards this Friday 3/5/2022
LIC308-Designation of Facility Responsibility
LIC500-Personnel Report
LIC 610D-disaster Plan
Register of Clients
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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