<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803764
Report Date: 12/02/2022
Date Signed: 12/02/2022 11:14:11 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20221027121106
FACILITY NAME:OUR HOUSEFACILITY NUMBER:
126803764
ADMINISTRATOR:SHANNON, ALEXANDERFACILITY TYPE:
735
ADDRESS:3309 MONTGOMERYTELEPHONE:
(707) 268-0679
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:4CENSUS: 4DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sara MeltonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication is not being dispensed to clients per doctors orders
Facility is in disrepair
Facility staff are not wearing masks
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At aproximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings to the above allegations. LPA met with Licensee Sara Melton. Based on interviews conducted and a review of records, facility did not assist clients with medications as ordered by physician. Medications were not ordered timely and were not administered as directed. Facility received refresher training from Redwood Coast Regional Center on 11/18/2022. LPA observed holes in the walls that have not been repaired in several months. Sara told LPA a contractor has been scheduled to repair the holes and will be coming early January. The bathroom tub surface is peeling and rough which could cause it to be difficult to clean. Sara has the supplies to resurface the floor and a contractor was supposed to complete the repairs but was delayed due to Covid. They will reshedule this month. On previous visits, LPA observed staff not wearing face coverings inside the facility. During this visit, all staff were wearing face coverings. Continued on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20221027121106

FACILITY NAME:OUR HOUSEFACILITY NUMBER:
126803764
ADMINISTRATOR:SHANNON, ALEXANDERFACILITY TYPE:
735
ADDRESS:3309 MONTGOMERYTELEPHONE:
(707) 268-0679
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:4CENSUS: 4DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sara MeltonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At aproximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings to the above allegation. LPA met with Licensee Sara Melton. Based on interviews conducted and LPA observations, there were no incidents of staff violating Clients personal rights. LPA observed clients rooms and found a lock on a closet door. This lock is installed with responsible party and Regional Center knowledge due to client behavior with person items. Client has access to personal items anytime with staff assistance.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20221027121106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOUSE
FACILITY NUMBER: 126803764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2022
Section Cited
CCR
80075(b)
1
2
3
4
5
6
7
80075 Health Related Services:(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on
1
2
3
4
5
6
7
Redwood Coast Regional Center provided medication training to all staff on 11/18/2022. POC cleared during visit.
8
9
10
11
12
13
14
records reviewed, Licensee did not ensure medications were provided per physician orders. This poses an Immediate Health, Safety or Personal rights risk to clients in care.
8
9
10
11
12
13
14
Type B
12/23/2022
Section Cited
CCR
80087(a)
1
2
3
4
5
6
7
80087 Buildings and Grounds:(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.This requirement is not met
1
2
3
4
5
6
7
Licensee to repair bedroom walls and repair bathtub floor. Photos of completed repairs to be submitted to CCL by POC date of 12/23/2022.
8
9
10
11
12
13
14
as evidenced by:Based on LPA observation, client bedroom had several holes in the wall and client bathtub was in need of repair. This poses a potential Safety risk for clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20221027121106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOUSE
FACILITY NUMBER: 126803764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
80072 Personal Rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet client needs.This requirement is not met as evidenced by: Based on
1
2
3
4
5
6
7
Licensee agrees staff will comply with goverment manates regarding the wearing of face coverings while providing care to clients. POC cleared at time of visit.
8
9
10
11
12
13
14
observations, Licensee did not ensure cilents in care receive safe and healthful accommodations in that facility staff were not wearing face coverings in violation of official government orders, requiring the wearing of face coverings while providing care and supervision to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20221027121106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OUR HOUSE
FACILITY NUMBER: 126803764
VISIT DATE: 12/02/2022
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
26
27
28
29
30
31
32
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


This report was reviewed with Sara Melton and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5