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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803764
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:41:33 PM

Document Has Been Signed on 01/31/2023 12:41 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
01/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alex ShannonTIME COMPLETED:
01:00 PM
NARRATIVE
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At approximately 11:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to a medication error reported by facility. LPA met with Administrator Alex Shannon. Facility has met with Redwood Coast Regional Center to receive additional training in medication management. As this error is a repeat violation of the same regulation in a 12 month period, a civil penalty is being assessed in the amount of $250.

LPA provided information regarding additional support the Department can provide with the Technical Support Unit. LPA also informed that Alex that an informal meeting will be scheduled to discuss recent areas of concern.

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 Alex Shannon and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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 01/31/2023 12:41 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 01/31/2023 at 11:39 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: OUR HOUSE
FACILITY NUMBER: 126803764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2023
Section Cited
CCR
80075(b)

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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
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Redwood Coast Regional Center provided additional instruction on medication practices and procedures. POC cleared during visit.
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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.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023


LIC809 (FAS) - (06/04)
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