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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803683
Report Date: 02/08/2024
Date Signed: 02/08/2024 11:51:19 AM

Document Has Been Signed on 02/08/2024 11:51 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: 4DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Hanna Peralta (Administrator)TIME COMPLETED:
12:06 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Hannah Peralta, Erica Ng Licensee, Ley Arquisola, Nurse Consultant III from DDS, Nayeli Hidalgo RN consultant from North Bay Regional Center was also present at the time of visit. All clients were attending day program during visit.

LPA/Administrator initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature. Resident rooms were furnished per regulation. Water temperature in client bathroom measured at 114.4 and 114.6 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cleaning supplies stored under kitchen sink and in garage were inaccessible to residents in care. Knives and other items that could pose a risk were locked. Medications were centrally stored and locked. Fire extinguishers are due to be serviced July 2023. 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 fire/disaster drill was completed 1/15/2024. Cash resources were reviewed. Full bed rails and PRN waiver on file. 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.

At approximate 9:15am, LPA/Administrator observed two cans of green beans were expired on December 2023.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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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: 02/08/2024
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Continued from LIC809...

At approximate 9:30am LPA/Administrator observed facility fence was pushed inwards. Per Administrator, the fence was damaged due to strong winds that occurred this past weekend in the area and provided LPA with work order #029662 dated 2/6/24 at 4:01pm that they have reported to the landlord. A technical violation will be issued.

At approximate at 9:45am LPA/Administrator inspected facility van that contained a fire extinguisher and first aid kit. However, there were medications (neomycin antibiotic ointment, ibuprofen and aspirin) that were expired since 2020. During spot check of medications conducted it was unclear if vitamin C 500 mg 1tab by mouth twice daily at 7am and 7 pm was provided to client (C1), because it was missing staff initials in the medication administration record for January 31, 2024.

File review was initiated at 10:00 am. Four staff files and four 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 7/17/24.

Licensee/Administrator to submit updates of the following documents by 2/22/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Affidavit Regarding Client Cash Resources (LIC 400), copy of current Surety Bond and Emergency Disaster Plan (LIC610E).

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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/08/2024 11:51 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 02/08/2024 at 11:34 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Administrator observed two cans of green beans were expired on December 2023, which is an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Administrator immediately discarded expired food. Administrator agreed to revise all food and will submit a self-certification LIC9098 form to ensure that expired food is discarded by POC due date.
Type A
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 LPA/Administrator's observations, records review and interviews with staff the licensee did not comply with the section cited above in C1's medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Administrator will review all client's medications to ensure compliance with regulation. Administrator will submit LIC9098 self-certification form to CCL to clear the citation.
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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


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