176800965-2-9-2023-21-AS-SHAN-CNVQZ6-20230209113613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 176800965
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:36:27 AM

Document Has Been Signed on 02/09/2023 11:36 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 HOME		FACILITY NUMBER:	176800965
ADMINISTRATOR:	FITTS, JENNIFER		FACILITY TYPE:	735
ADDRESS:	15190 KONOCTI VIEW		TELEPHONE:	(707) 295-7710
CITY:	CLEARLAKE	STATE: CA	ZIP CODE:	95422
CAPACITY: 5		CENSUS: 3	DATE:	02/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jennifer Fitts, Licensee		TIME COMPLETED:	11:45 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 9:45 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 105.1 degrees F. within Title 22 acceptable regulation of 105 to 120 degrees F in client’s bathrooms. Fire extinguishers are fully charged and last inspected. Smoke alarm and Carbon Monoxide detector were tested and in working order, facility is installing new fire and alarm monitoring system that will alert their phones and fire department. Disaster Drills are conducted twice yearly, with the last drill conducted 12/18/2022. Facility does not handle client monies. Facility has recently had some water damage to the roof due to weather conditions and have contractors scheduled to fix. Facility will send pictures of completion.

Infection Controle:

Facility has submitted Mitigation Program Plan and Infection Control Plan. Facility has PPE supply stored in office in kitchen cabinet. Staff are all fully boosted.

LPA reviewed Licensing Information System (LIS) with Licensee who stated that is correct and updated at this time; although requesting to update main phone number and email, will be sending LIC200 . 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: 02/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FERRIS HOME	FACILITY NUMBER: 176800965
	VISIT DATE: 02/09/2023

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LPA was presented with proof of CPR & 1^st 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 2/23/2023 to SRRO:

LIC308-Designation of Facility Responsibility
LIC500-Personnel Report
LIC 610D-disaster Plan
LIC 9020 Register of Clients

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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