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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801572
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:18:54 PM

Document Has Been Signed on 07/28/2023 02:18 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:
486801572
ADMINISTRATOR:OKEIGWE, HELENFACILITY TYPE:
735
ADDRESS:2201 TUOLUMNE STREETTELEPHONE:
(707) 558-1777
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 46CENSUS: 43DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Helen Okeigwe, Administrator
TIME COMPLETED:
12:42 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with Michelle Sheldon (S1), Program Director and Helen Okeigwe, Administrator.

During todays inspection, LPA toured the inside and outside of the facility, with S1 and found the facility clean, at a comfortable temperature with all exits free from obstruction. This facility is a one level facility, licensed for 46 Ambulatory clients. All bedrooms were observed to have the required furniture and facility has a closet full of linens, that are available for clients to use. Extra hygiene products and linens are available. Water temperature in resident's bathrooms is within the required 105 to 120 degrees. Toxins are located in locked closet. Kitchen was well organized, clean and food was observed with covers. Dining area, tables and food counters were observed clean. Perishable and non-perishable foods were sufficient. Facility has emergency food and water available in kitchen storage.

Fire extinguishers located throughout the facility were last inspected January, 5, 2023. The facility has a hard wired sprinkler system and smoke alarm system that is inspected every six months by Pyro Communication Systems. There are Carbon monoxide detectors throughout the facility that are functional. The last disaster drill was conducted and documented 6/12/2023.

Medications were centrally stored and locked and a sample was reviewed. Logs are kept of medication administration and prescription receipt. A sample of facility client and staff files were reviewed and found complete. Administrator certificate for Helen Okeigwe #6003732735 expired July 16, 2023, but was submitted for renewal. Staff have proof of current First/Aid CPR.

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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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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: 07/28/2023
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Administrator and LPA discussed the Infection Control Plan. LPA went over Reporting Requirements.

Licensee/Administrator to submit the current following documents by 8/28/2023:



Infection Control Plan of Operation (If changes)

Facility provided LPA with the following updated document during today's inspection.

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610 Emergency Disaster Plan
· LIC 9020 Register of Facility Residents

Facility will submit a copy of Administrator Certificate, when they receive.

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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