496803687-2-13-2024-21-AS-CCOO-D2ESF3-20240213124938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803687
Report Date: 02/13/2024
Date Signed: 02/13/2024 12:50:12 PM

Document Has Been Signed on 02/13/2024 12:50 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	ERIKA'S HOME		FACILITY NUMBER:	496803687
ADMINISTRATOR:	ELIZABETH WISE		FACILITY TYPE:	735
ADDRESS:	2307 WARWICK DRIVE		TELEPHONE:	(707) 843-7310
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY: 4		CENSUS: 3	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Elizabeth Wise, Administrator		TIME COMPLETED:	01:05 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) Christi Coppo arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Elizabeth Wise. Clients were attending to celebration program. Required postings observed. At approximately 9:00am LPA and Admin toured the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Bedding observed to be clean and in good repair. Water temperature in client bathrooms measured at 113.1 and 112.6 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two [2] days of perishable foods and seven [7] days of non-perishable foods. Food was found to be stored in a safe manner with open items covered and labeled. Emergency supply of food and water present. Medications are centrally stored and locked. At approximately 12:00pm LPA and Admin did a spot check of medications and medication records were reviewed. Facility utilizes a MAR, LPA reviewed MAR entries, no discrepancies observed. During spot check of medication, LPA and Admin observed one bottle of Fluticasone exp date of 6/20/2024, had expiration date incorrectly entered on Centrally Stored Medication log (CSML) and one bottle of Ketotifen exp date of 1/1/2025 also had expiration date incorrectly entered on CSML. Per Title 22 regulation 80075(k)(7)(F) Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (F) Expiration date (deficiency cited, see 809D). Continued on 809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ERIKA'S HOME	FACILITY NUMBER: 496803687
	VISIT DATE: 02/13/2024

NARRATIVE

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Continued from 809...

Fire extinguishers were last inspected July 27, 2023. Smoke/carbon monoxide detectors were tested and functional at the time of inspection. Facility's most recent fire drill was conducted 2/5/2024.

At approximately 10:00am LPA reviewed three [3] out of three [3] resident files. All required documents present. At approximately 11:00am LPA reviewed five [5] out of five [5] staff files. Staff have required First Aid certificates and Pro-Act certificates. Administrator Certificate for Elizabeth Wise, 6061070735, expires on 4/8/2025.

At approximately 11:45am Cash Resources were reviewed. No discrepancies.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Surety Bond

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2024 12:50 PM - It Cannot Be Edited

Created By: Christi Coppo On 02/13/2024 at 12:29 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ERIKA'S HOME	FACILITY NUMBER: 496803687
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(7)(F)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (F) Expiration date. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that one bottle of Fluticasone exp date of 6/20/2024, had expiration date incorrectly entered as 1/17/2025 on CSML and one bottle of Ketotifen exp date of 1/1/2025, had expiration date incorrectly entered as 1/17/2025 on CSML which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2024
	Plan of Correction
1 2 3 4	Admin to submit LIC9098 self-certifying plan of how they will properly log medications on the CMSL. Admin to submit written plan along with LIC9098 by plan of correction due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Bethany Moellers

LICENSING EVALUATOR NAME:

Christi Coppo

LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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