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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803687
Report Date: 04/17/2023
Date Signed: 04/17/2023 04:30:36 PM

Document Has Been Signed on 04/17/2023 04:30 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:ELIZABETH WISEFACILITY TYPE:
735
ADDRESS:2307 WARWICK DRIVETELEPHONE:
(707) 843-7310
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 4CENSUS: 4DATE:
04/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Shift Lead, Roberto Torres
Administrator, Elizabeth Wise		TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Erika's Home for the purpose of conducting a Case Management-Incident inspection. LPA was greeted at the door by Shift Lead, Roberto Torres, and was granted access into the home. Administrator, Elizabeth Wise arrived 20 minutes later. The purpose of this Case Management-Incident Inspection is to follow-up on incident reports dated for April 5, 2023 and April 17, 2023.

During the Case Management-Incident inspection, LPA reviewed the LIC 602 for a client in care and staff Pro-Act restraint documentation. Furthermore, LPA interviewed the Administrator and Client in care regarding the incidents.

No deficiencies were observed or cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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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