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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803687
Report Date: 02/10/2022
Date Signed: 02/10/2022 03:22:23 PM

Document Has Been Signed on 02/10/2022 03:22 PM - 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:ERIKA'S HOMEFACILITY NUMBER:
496803687
ADMINISTRATOR:BERNARDO, JUGIEFACILITY TYPE:
735
ADDRESS:2307 WARWICK DRIVETELEPHONE:
(707) 843-7310
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 4CENSUS: 4DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Jugie BernardoTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 1:30 PM, and met with administrator Jugie Bernardo. The inspection is focused on the Infection Control procedures and practices of this facility. LPA was initially greeted by staff, administrator arrived shortly.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per administrator, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through their nurse consultant. Staff have been N95 fit tested. High touch surface areas are disinfected twice a shift. Due to current facility census residents could isolate in their own bedrooms if necessary. LPA observed necessary PPE to support a resident in isolation in garage.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents in locked garage cabinet. Medications are centrally stored and inaccessible to residents. Facility is conducting COVID-19 surveillance testing per CCL guidelines. Three out of four residents have received their booster shot.



Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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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: ERIKA'S HOME
FACILITY NUMBER: 496803687
VISIT DATE: 02/10/2022
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. Facility has a recreational therapist who provides activities for the clients. Visitation is being allowed indoors and outdoor.

LPA provided guidance to review PIN 22-07

LPA is requesting the following forms be updated and submitted to CCL:
· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan
· LIC 308 - Designation of Responsibility

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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