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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803683
Report Date: 06/04/2024
Date Signed: 06/04/2024 10:00:22 AM

Document Has Been Signed on 06/04/2024 10:00 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: 4DATE:
06/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:34 AM
MET WITH:Hanna Peralta (Administrator)TIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Cuadra arrived at facility unannounced to conduct a case management and met with Administrator Hanna Peralta to follow up on outstanding fees in the amount of $681.

On May 22, 2024 The Department had notified Administrator in writing regarding the annual fees due including late fees accrued. Licensing Agency received no response. During today's visit, LPA discussed with Administrator regarding the outstanding late fees. Per Administrator, the licensee's mailing address is not updated in the system and they did not have the PIN to make the required payment. LPA provided Administrator with PIN and Administrator made a payment (confirmation #935235) to Licensing Department for the outstanding amount of $681 while LPA was at the facility to avoid further late fee penalties. Also, Administrator agreed to submit an updated LIC200 to reflect the changes and

No deficiencies cited during today's visit.

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: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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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