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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803687
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:57:18 PM

Document Has Been Signed on 02/02/2023 03:57 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:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator, Elizabeth WiseTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/02/2023 to conduct a required - 1 year inspection. This inspection is focused on the infection control practices and procedures of this facility. LPA met with administrator Elizabeth Wise.

Upon arrival LPA was signed in and screened. LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. Bedrooms were appropriately furnished. Extra hygiene supplies and linens were available for clients. Bathrooms had necessary grab bars and nonskid mats. Carbon monoxide and smoke detectors were present and operational throughout the facility. Fire extinguishers were charged and current. Facility had sufficient perishable and nonperishable food. Toxins were locked and secured. Medications were locked and secured. Staff and clients are fully vaccinated and boosted. Facility disinfects daily. Staff have received infection control training.

LPA followed up regarding incident report received on 01/27/2022. Facility self reported medication error where a client was accidentally given a medication 4 hours later than was required. Error was noticed by staff and physician was notified. Client was monitored and no adverse effects were noted. Facility to undergo training by nurse consultant on 02/03/2023. LPA was provided with affidavit regarding staff training. LPA is requesting copies be sent to Community Care Licensing (CCL) once training is completed. LPA has assessed a technical violation.

LPA is requesting the following documents be submitted to CCL within 30 days of today's inspection: LIC 500 Personnel Report, LIC 9020 Client Roster, LIC 400 Affidavit Regarding Client Cash Resources, LIC 402 Surety Bond, LIC 610 Emergency Disaster Plan, and LIC 308 Designation of Facility Responsibility

Exit interview conducted with administrator and a copy of this report emailed to the facility. No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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