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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803664
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:07:52 AM

Document Has Been Signed on 06/23/2022 11:07 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:ERIC'S HOMEFACILITY NUMBER:
496803664
ADMINISTRATOR:RAMA, MHARC DELAFACILITY TYPE:
737
ADDRESS:1944 HIDDEN VALLEY DRIVETELEPHONE:
(707) 303-7961
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 4DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator, Mharc Dela RamaTIME COMPLETED:
11:17 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and initially met with facility staff. Administrator, Mharc Dela Rama arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that they will be screened and the visitation policy of the facility. LPA was screened at the front door by a staff and then asked to enter through the backyard per the facility's protocol. LPA initiated a walk-through of the facility around 9:20am and observed the following: LPA was shown the screening area in the garage where staff are screened prior to coming on shift. LPA reviewed staff and client screening documentation. Clients are screened twice per day. LPA confirmed with staff and Administrator that staff are conducting vaccination verification for visitors per Provider Information Notice (PIN) 21-40-ASC Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is locked to ensure client safety but hand washing supplies are located at sinks and clients are given hand sanitizer when needed. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected twice per shift.

Staff continue to be training regarding infection control and donning and doffing of PPE. Staff have been N95 fit tested. Administrator and LPA discussed re-testing staff for N-95 mask wearing. LPA and Administrator discussed visitation and activities.

Continued on LIC809

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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: ERIC'S HOME
FACILITY NUMBER: 496803664
VISIT DATE: 06/23/2022
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Continued from LIC809

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced August 2021. Facility has a centralized fire system that is serviced quarterly and was last serviced February 2022.

Administrator and LPA discussed their Emergency Disaster Plan and the Infection Control Plan. Infection Control Plan is due by June 30, 2022.

Licensee/Administrator to submit updates of the following documents by 7/23/2022:


LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources (if changes)
LIC 402 Surety Bond (if changes)
LIC 9020 Register of Facility Client’s

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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