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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803683
Report Date: 08/30/2022
Date Signed: 08/30/2022 12:08:13 PM

Document Has Been Signed on 08/30/2022 12:08 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:ERAH HOMEFACILITY NUMBER:
496803683
ADMINISTRATOR:PERALTA, HANNAH CFACILITY TYPE:
734
ADDRESS:1466 COUNTRY MANOR DRIVETELEPHONE:
(707) 843-7251
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 5DATE:
08/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Hanna Peralta (Administrator)TIME COMPLETED:
12:23 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Other Visit, and met with Hanna Peralta Administrator. The purpose of this Case Management Visit is to follow up on another agency report submitted to Community Care Licensing (CCL).

During the inspection LPA/staff toured the kitchen of the facility and approximate at 11:23am LPA/staff observed one drawer unlocked containing sharp objects such as knives, scissors and unlocked cabinet under kitchen sink with toxins including cleaning solutions, disinfectants and other items that could pose a danger when they are accessible to clients in care (80087g). LPA/Administrator discussed the importance of locking toxins and dangerous items that could pose a danger to clients in care.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with administrator and a copy of this report was printed for the facility.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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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Document Has Been Signed on 08/30/2022 12:08 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/30/2022 at 11:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ERAH HOME
FACILITY NUMBER: 496803683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2022
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds - (g) Disinfectants, cleaning solutions, poisons, ... and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Administrator was asked to lock the items during the visit. Administrator will train all staff on regulation 80087(g) and submit a copy with date, time, duration, subject, attendees and their signatures to Community Care Licensing (CCL) to clear the citation by POC due date 08/31/2022
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Based on LPA observations and interviews conducted, Administrator did not ensure the regulation above do to cleaning solutions, disinfectants and other items that could pose a danger were observed unlocked and accessible to clients. This is an immediate health & safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
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