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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803687
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:58:55 AM

Document Has Been Signed on 09/29/2023 10:58 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:
09/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Elizabeth WiseTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived 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 was made aware that the staff member was recently terminated on September 5, 2023 due to an incident occurring on September 4, 2023. Client was not able to be interviewed during this Case Management-Incident Inspection. LPA requested the following documents:

-Staff file
-Pro-Act restraint certificate
-Disciplinary records (if any)
-Termination documents


Also during this Case Management-Incident Inspection, LPA reviewed an incident report with the Administrator indicating that the facility did not administer a medication dosage to a client in care. Based off the incident report dated for September 29, 2023, a client was not administered the morning medication on September 28, 2023. Administrator confirmed the date and time which the medication was missed during the Case Management-Incident inspection.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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Document Has Been Signed on 09/29/2023 10:58 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 09/29/2023 at 10:41 AM
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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2023
Section Cited
CCR
80075(b)

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80075(b) Health Related Services:

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidenced by:
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Plan of Correction (POC) ALL staff meeting will be conducted as well as training.

LPA requested a plan for future compliance as it relates to this regulation and how it will be followed in the future. Administrator shall submit an LIC 9098 self certification which entails that the Administrator understands the regulation.
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Based off the incident report dated for September 29, 2023, a client was not administered the morning medication on September 28, 2023. Administrator confirmed the date and time which the medication was missed which is an immediate health, safety and personal rights risk to the client(s) in care.
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Plan of Correction as it relates to the plan for future compliance and the LIC 9098 is due on October 2, 2023.

Training documents due on October 6, 2023.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
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