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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176800965
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:44:27 PM

Document Has Been Signed on 09/15/2022 04:44 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:FERRIS HOMEFACILITY NUMBER:
176800965
ADMINISTRATOR:FITTS, JENNIFERFACILITY TYPE:
735
ADDRESS:15190 KONOCTI VIEWTELEPHONE:
(707) 295-7710
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 5CENSUS: 2DATE:
09/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Administrator Jennifer FittsTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with Jennifer Fitts, Administrator. The purpose of this case management inspection is to follow up on a self reported incident reprot submitted to Community Care Licensing (CCL) 8/16/2022 that was first attempted on 8/29/2022.

CCL received a self reported incident reporting on 8/14/2022 at 6:45 PM client (C1) left facility, had an in counter with local law enforcement, and was hospitalized. C1 was admitted to hospital. Facility expressed C1 does not want to return to facility.

LPA observed a trailer parked on the driveway of the front entrance of facility full of garbage. The container is full of used carpet topped with garbage bags. LPA consulted and advised facility, trailer and contents will need to be removed. Failure to remove trailer and contents may result in future citations.

LPA issued a technical advisory during this visit, no citations issued at this time.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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