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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804155
Report Date: 01/04/2024
Date Signed: 01/04/2024 12:22:22 PM

Document Has Been Signed on 01/04/2024 12:22 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:HE&RT LLCFACILITY NUMBER:
496804155
ADMINISTRATOR:NG, ERICAFACILITY TYPE:
734
ADDRESS:5679 QUEEN ANNE DR.TELEPHONE:
(707) 479-0276
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 3DATE:
01/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Hannah Peralta, Co-AdministratorTIME COMPLETED:
12:36 PM
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Licensing Program Analyst (LPAs) Christi Coppo arrived unannounced to continue pre-licensing inspection and was greeted by Monica Damsten, Psychiatric Technician. Facility Administrator, Erica Ng not available as she has tested positive for COVID. LPA verified that staff and residents in facility have all been tested. Per Psych Tech, everyone has tested negative. Co-Administrator Hannah Peralta arrived later at approximately 10:40am. Facility currently has three residents in care.

At approximately 9:20am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. Outside in the backyard, LPA observed ping pong/activity table propped up by a ladder and 2 metal chairs which poses a potential hazard. LPA observed obstructed fire exit path on backyard cement area leading to wooden deck. Path obstructed by:
  • stacks of plastic chairs, stacked up at approximately 3.5 feet tall,
  • one large table umbrella,
  • large cactus planter approximately 36 inches in diameter,
  • one outdoor patio table approximately 44 inches in diameter,
  • piece of wrap-around bench approximately 6 feet long.

Bench was part of wrap-around bench seating on the deck in the backyard. Bench has white and black spots on underneath side of legs and is exhibiting signs of deterioration. Bench is laid horizontally on its side, cutting off access to fire exit path on side of facility and access to deck. Square umbrella table stand placed behind bench and cactus planter adding to blocked fire exit path.

LPA advised that Admin must remove all items blocking backyard fire exit path and secure ping pong/activity table. Staff immediately removed all items obstructing path of backyard fire exit.

Continued on 809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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: HE&RT LLC
FACILITY NUMBER: 496804155
VISIT DATE: 01/04/2024
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Continued from 809...

Items required to be addressed as identified in initial pre-licensing inspection that have been addressed satisfactorily:
  • Facility has removed partition blocking entrance to living room,
  • White gate in backyard has been repaired, the top screw is now present, gate is now functional,
  • Hose that was previously a tripping hazard has been removed,
  • Walkways are now mostly clear of falling acorns such that their being a tripping hazard as been mitigated.

Admin agrees to continue to mitigate risk of tripping hazard caused by falling acorns by keeping walkways clear. Admin to submit LIC9098 by January 15, 2024 with pictures fire exit path in backyard showing it is still free from obstruction. Admin to submit pictures of cleared walkway along with pictures of backyard fire exit free from obstruction.

Once acceptable photographic proof is received by CCL, LPA will submit facility's application for approval.

Comp III reviewed and exit interview conducted with Co-Administrator and a copy of this report given.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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