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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801572
Report Date: 11/06/2025
Date Signed: 11/06/2025 12:50:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
10/23/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20251023104201
FACILITY NAME:OUR HOUSEFACILITY NUMBER:
486801572
ADMINISTRATOR:MICHELE SHELDONFACILITY TYPE:
735
ADDRESS:2201 TUOLUMNE STREETTELEPHONE:
(707) 558-1777
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:46CENSUS: 43DATE:
11/06/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Gina Young, Clinic NurseTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Lack of Care and Supervision
Medications Not Properly Administered
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Clinic Nurse, Gina Young. Administrator Nicole Paiste was contacted via phone call and gave permission for Clinic Nurse to sign and receive report.

During the course of this investigtion LPA made observation, reviewed records, and conducted interviews.

Lack of Care and Supervision – Reporting Party (RP) alleges that facility allows client (C1) to leave facility unsupervised and did not call for medical treatment when required by C1. Review of C1 LIC602 – Physician Report indicated that per physician’s orders C1 is able to leave the facility unassisted and has the capacity for self-care.

Continued LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
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 4
Control Number 21-AS-20251023104201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: OUR HOUSE
FACILITY NUMBER: 486801572
VISIT DATE: 11/06/2025
NARRATIVE
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Continued from LIC9099...

Review of Incident Report (IR) submitted to Community Care Licensing (CCL) by the facility on 9/29/2025 indicated that the facility called emergency services to have C1 taken to the Emergency Room upon being informed by C1 that they were suffering from pain. Review of Appraisal/Needs and Service Plan indicated that the facility is assisting C1 maintain sobriety, maintain a healthy diet, develop tools for success, and socialize with their peers.

Medications Not Properly Administered – RP alleges that they do not believe medications for R1 were correctly given. Review of C1 LIC602 – Physician Report indicated that per physician’s orders C1 is able to administer and store their own medications, however, medications would be stored by the facility. Review of C1 Preplacement Appraisal Information indicated that C1 did not require assistance with medication. Review of C1 PRN Authorization Letter indicated physician order that C1 “can determine and clearly communicate his/her need for prescription and nonprescription medications on a PRN basis”. Review of C1 Medication Administration Record (MAR) for September 2025 and October 2025 indicated seventy-five (75) instances of C1 refusing medication, as is their right per regulation 80075(b)(2). Further review of C1 MAR indicated various instances of an X in place of a medication administration code; a symbol not defined in MAR Chart Codes. Interview with Clinic Nurse (CN) indicated that X is for medication that has been discontinued or not started yet.

Based upon observations, interviews, and record review the department has found that 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/complaint are UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted with Clinic Nurse, whose signature on form confirms receipt.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4