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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803683
Report Date: 05/13/2022
Date Signed: 05/13/2022 10:04:18 AM

Document Has Been Signed on 05/13/2022 10:04 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:PERALTA, HANNAH CFACILITY TYPE:
734
ADDRESS:1466 COUNTRY MANOR DRIVETELEPHONE:
(707) 843-7251
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 5DATE:
05/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Loc Nguyen (LVN)TIME COMPLETED:
10:15 AM
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LPA Cuadra arrived unannounced to conduct a case management inspection was greeted by staff, Loc Nguyen. Administrator, Hanna Peralta was not able to come to the facility, but gave authorization to staff to sign the report. Nayeli Hidalgo RN consultant from North Bay Regional Center was also present at the time of visit. LPA conducted risk assessment with staff prior to the visit. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

LPA is following up on an incident received on 4/26/22 from Administrator regarding client (C1). On 4/21/22 Administrator received a call from RN consultant NBRC who have found a medication error on C1's treatment of Nystop 100,000 powder, that needed to be applied to axilla daily and had an expiration date of 4/16/22. Upon notification, Staff on duty was instructed to discard medication right away and follow medication discard policy and start the newly filled Nystop powder. C1's skin was intact and dry, no adverse reactions were noted. Also, facility provided a staff training on medication administration, medication handling and storage, controlled drug policy and procedure.

During today’s visit LPA reviewed C1’s file, staff training records dated 4/28/22 regarding review and re-training on medication management and administration policy and procedures. Facility created a log that will track all PRN medications and treatment orders including their expiration date; One LVN will be assigned monthly to check on each client's medications.

No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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