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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803683
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:55:05 AM

Document Has Been Signed on 02/13/2025 11:55 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
SANTA ROSA RO, 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:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:48 AM
MET WITH:Administrator Hannah PeraltaTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPAs) Deniz and Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Hannah Peralta. All clients were attending day program during visit.

LPAs/Administrator initiated a tour of the facility at 9:30 am and made the following observations: Facility was a comfortable temperature. Resident rooms were furnished per regulation. Water temperature in client bathroom measured at 112.6 and 115.3 degrees F which is within allowable range of 105 to 120 degrees F. During todays visit LPAs have follow up on areas of concern identified by another agency semi-annual review, regarding building and grounds, LPAs observed a drain cover in located bathroom # 1. Also, LPAs reviewed medication records and conducted a spot check of medications did not reveal any discrepancies. 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 charged and serviced May 2024. 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 1/15/2025. 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. LPAs 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.
Continued on LIC809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ERAH HOME
FACILITY NUMBER: 496803683
VISIT DATE: 02/13/2025
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Continued from LIC809...
LPAs/Administrator inspected facility van that contained a fire extinguisher and first aid kit.

File review was initiated at 10:30 am. Six 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.

Licensee/Administrator to submit updates of the following documents by 2/20/2025: 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).

No deficiencies cited during the inspection.

Exit interview was conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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