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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803683
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:59:35 AM

Document Has Been Signed on 01/27/2023 11:59 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:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Hanna Peralta (Administrator)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator, Hanna Peralta.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Administrator conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Automatic wall mounted hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least three times a day. Facility is allowing indoor visitation. Each client has their private room and facility is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication.Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Four out of five clients do attend to day program and the facility provides activities for client that doesn't attend to day program. Clients receive indoor visitation with their families. Facility has submitted their Covid Mitigation Plan and approved on 3/8/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff. Fire extinguishers were serviced and charged as of October, 2022. Last disaster drill was conducted on 1/15/23. During today's visit, Administrator informed LPA about an issue with one out of two bathrooms that has been draining the water slowly so the facility is working very closely with landlord, DDS and NBRC to address the issue. Administrator agreed to provide CCL with an updated plan by 2/10/23.
Administrator will provide updates of the following by 2/10/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), affidavit regarding client/resident cash resources (LIC400), surety bond, Emergency Disaster Plan (LIC610E), Administrative Organization (LIC309) and lease agreement.
Exit interview conducted with Administrator and a copy of this report was given.
No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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