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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801572
Report Date: 07/29/2022
Date Signed: 07/29/2022 11:14:41 AM

Document Has Been Signed on 07/29/2022 11:14 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:OUR HOUSEFACILITY NUMBER:
486801572
ADMINISTRATOR:OKEIGWE, HELENFACILITY TYPE:
735
ADDRESS:2201 TUOLUMNE STREETTELEPHONE:
(707) 558-1777
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 46CENSUS: 44DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Helen Okeigwe, Program AdministratorTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced required 1 year inspection at Our House and was welcomed by Program Director, Michele Sheldon. Program Administrator, Helen Okeigwe was also contacted and notified and arrived later during the visit. There are currently 44 clients served within the facility.

LPA arrived at approximately 9:25am and continued tour of the facility with Program Director. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/24/2022 at the time of the visit. Facility smoke detectors and carbon monoxide were all connected under one system with the last fire inspection conducted on 5/23/2022 with an updated fire clearance granted on 4/25/2022. LPA conducted a medication procedure review and found to be in order.

Clients were observed to be engaged with staff and one another in common areas. There was sufficient amount of supply for both perishable and nonperishable foods as required by Title 22 Regulations. There was a supply of cleaners, hygiene products and paper products available for clients. LPA conducted sample review of staff 1st Aid & CPR certification and found records to be updated.


Infection Control:
Facility has submitted COVID Infection Control Plan for review. Posters have been placed at the main entrance, restrooms and facility hallways with proper COVID mitigation protocols. Updated COVID protocols have been implemented with proper isolation plan and PPE usage. Facility has a station at main entrance with a thorough sign in system, thermometer, hand sanitizer and other items designated for visitors and staff. Visitation is typically conducted in the front courtyard area encourage social distancing. LPA was provided with proper PPE equipment including, N95 mask, gown and face shield. Staff and clients are also screened on a daily basis and throughout the day.

Report continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OUR HOUSE
FACILITY NUMBER: 486801572
VISIT DATE: 07/29/2022
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LPA requested the following updated documents be sent to CCL by COB 8/5/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
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