<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803687
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:54:14 PM

Document Has Been Signed on 04/15/2022 03:54 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:
04/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator, Jugie BernardoTIME COMPLETED:
04:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 04/15/2022 to conduct a case management inspection. LPA met with administrator, Jugie Bernardo. Administrator called LPA on 04/06/2022 and left a message to report a medication error. Administrator submitted incident report on 04/06/2022.

LPA and administrator discussed medication error. Training was conducted for 4 staff involved in medication error on 04/11/2022. Training was given by Nurse Consultant. LPA obtained copy of training material.

No deficiencies cited during this inspection.

Exit interview conducted with administrator and a copy of this report printed for the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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 1