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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803687
Report Date: 10/09/2023
Date Signed: 10/09/2023 10:44:10 AM

Document Has Been Signed on 10/09/2023 10:44 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
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:
10/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Elizabeth WiseTIME COMPLETED:
11:00 AM
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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 Administrator, Elizabeth Wise, and was granted access into the facility.

During the Case Management-Incident inspection, LPA obtained termination paperwork and also requested the Administrator and the staff to fill out Declarations regarding the incident in question. LPA emailed the Declarations to the Administrators email address. LPA confirmed receipt of those Declarations.

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: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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