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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803664
Report Date: 07/10/2023
Date Signed: 07/10/2023 10:32:49 AM

Document Has Been Signed on 07/10/2023 10:32 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ERIC'S HOMEFACILITY NUMBER:
496803664
ADMINISTRATOR:JOHNSON-REED, MADISONFACILITY TYPE:
737
ADDRESS:1944 HIDDEN VALLEY DRIVETELEPHONE:
(707) 303-7961
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 4DATE:
07/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Madison Johnson-ReedTIME COMPLETED:
10:42 AM
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Licensing Program Analyst (LPA) Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Madison Johnson-Reed.

LPA is following up regarding a self-reported incident where a facility staff was observed interacting with a client in a manner that scared the client, violating their personal rights. Facility has done an investigation and the staff was terminated.

No deficiencies cited during this visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2023
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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