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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803683
Report Date: 02/03/2026
Date Signed: 02/03/2026 11:12:31 AM

Document Has Been Signed on 02/03/2026 11:12 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:ERAH HOMEFACILITY NUMBER:
496803683
ADMINISTRATOR/
DIRECTOR:		PERALTA, HANNAH CFACILITY TYPE:
734
ADDRESS:1466 COUNTRY MANOR DRIVETELEPHONE:
(707) 843-7251
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 5DATE:
02/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Hanna Peralta (Administrator)TIME VISIT/
INSPECTION COMPLETED:
11:27 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Hannah Peralta. Clients were attending day program during visit. Required postings observed. Annual fees are current.

LPA/Administrator initiated a tour of the facility and made the following observations: Facility was a comfortable temperature. Resident rooms were furnished per regulation. Hoyer lift equipment was working properly. Water temperature in client bathroom measured at 121.3 and 121.5 degrees F which is not within regulation. Extra hygiene products and linens were available. Cleaning supplies stored under kitchen sink and in garage were inaccessible to clients in care. Knives and other items that could pose a risk were locked. Medications were centrally stored and locked. Fire extinguishers are charged & serviced May 2025. Combination smoke/carbon monoxide alarms were tested and operational at time of inspection. The home is fire sprinkled and has interior fire doors. A generator is used as their second required power source. Most recent disaster drill was completed 1/15/2026. Emergency food and water for at least 72-hours. Facility has at least two days of perishable and one week of non-perishable foods. Currently there are clients who are fed through G-tubes. LPA was able to verify that facility maintains a 7+ day supply of client prescribed nutritional formulas and supplies. LVNs and RNs are responsible for all tube feeds and medications. LPA/Administrator inspected facility van that contained a fire extinguisher and first aid kit. At approximately 9:30am LPA/Administrator observed a non-working hoyer lift machine behind the shed located outside. Per Administrator, they are in the process to discard it (technical violation issued)Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: ERAH HOME
FACILITY NUMBER: 496803683
VISIT DATE: 02/03/2026
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Continued from LIC809...
LPA is following up on an incident received on 1/13/26 from Administrator regarding client (C1). Per incident report, on 1/11/26 Administrator received a call from RN consultant from NBRC who conducted an unannounced visit and during a spot of medication have found a medication error on C1's medication of melatonin 5mg administered via G-tube due at 8pm. Per RN, the medication was still in the bubble pack, but medication administration log was signed with licensed staff initial. Upon notification of the incident, Administrator initiated an investigation and interviewed pertinent staff. According to LVN, they might signed the medication administration record by mistake due to an interruption during medication preparation, LVN mistakenly assumed that medication was already given to C1 and medication was missed. On 1/12/26, incoming staff discarded the missed medication dose and documented in the centrally stored medication/destruction log and co-signed by licensed staff. C1 was monitored and no further incidents were noted. Responsible parties were notified. The facility provided a staff re-training on medication administration and medication handling. During today’s visit LPA reviewed C1’s file, staff training records dated 1/13/26 regarding review and re-training on medication management including documentation and administration records.
File review was initiated at 10:30 am. Four staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Training hours were complete. All clients have medical assessments and care plans updated. Administrator Certificate for Administrator, Hannah Peralta 6038008735, expires on 7/17/2026. Full bed rails and PRN waiver on file. Client's exceptions were reviewed. Medication and medication records were reviewed, no further discrepancies were noted.Cash resources were reviewed.
Licensee/Administrator to submit updates of the following documents by 2/11/2026: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), & copy of current Surety Bond.

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 was conducted with Administrator and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2026 11:12 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 02/03/2026 at 10:56 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: 02/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation and interview, the licensee did not comply with the section cited above in two out of two faucents used by residents measured 121.3 and 121.5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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Administrator agrees to adjust water temperature to measure within regulation. Administrator will monitor water temperature and will complete a 7-day log of water measurements, then they will submit it to CCL as proof of correction by not later than 2/11/26.
Type B
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on incident report submitted to CCL on 1/13/26, a third party agency conducted a sopt check of medication revealed a missed dose of C1's medication - melatonin 5mg, the licensee did not comply with the section cited above in one of C1's medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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Administrator conducted a staff re-training on 1/13/26 with all staff regarding medication administration and documentation. LPA was provided with staff training records dated 1/13/26. Deficiency is cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


LIC809 (FAS) - (06/04)
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