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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176800965
Report Date: 03/10/2025
Date Signed: 03/10/2025 02:34:44 PM

Document Has Been Signed on 03/10/2025 02:34 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:FERRIS HOMEFACILITY NUMBER:
176800965
ADMINISTRATOR/
DIRECTOR:		WILLIAM FERRISFACILITY TYPE:
735
ADDRESS:15190 KONOCTI VIEWTELEPHONE:
(707) 295-7709
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 5CENSUS: 3DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator William FerrisTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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License Program Analyst (LPA) Deniz arrived unannounced to conduct a Required 1-year Infection Control Inspection of the facility. LPA was welcomed by Licensee William Ferris. There are 3 clients enrolled in the program.

At approximately 9:45AM, LPA/Administrator toured the building and did following observations; grounds which was found in good repair. However, kitchen cabinet door under the kitchen sink was loose and need repair (Technical violation issued). Administrator informed LPA that they are already ordered new cabinet and kitchen appliances.

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 114.6- and 108.7 degrees F. within Title 22 acceptable regulation of 105 to 120 degrees F in client’s bathrooms and kitchen.

LPA/Administrator observed fire extinguishers are fully charged and indicator was on green, but last inspection was done on Feb 2023. Administrator called the service to book a service. Smoke alarm and Carbon Monoxide detector were tested and in working order, facility is installed a new fire and alarm monitoring system that will alert their phones and fire department.

Disaster Drills are last conducted drill conducted 12/18/2024. Facility does not handle client monies.




Continue LIC 809-C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FERRIS HOME
FACILITY NUMBER: 176800965
VISIT DATE: 03/10/2025
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Continue from LIC 809...


At approximately 11:45AM, LPA reviewed 3 resident files and 2 staff files, all fount to be in order and updated on file. Medication records are thorough and contained physician's orders for each resident.
LPA was presented with proof of CPR & 1st Aid certification for staff.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:



LIC308 – Designation of Facility Responsibility
LIC500 - Personnel Report
LIC610E - Emergency Disaster Plan
Evidence of Updated Liability Insurance



Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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