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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801572
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:17:44 PM

Document Has Been Signed on 06/13/2024 01:17 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/
DIRECTOR:
MICHELE SHELDONFACILITY TYPE:
735
ADDRESS:2201 TUOLUMNE STREETTELEPHONE:
(707) 558-1777
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 46CENSUS: 45DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Michelle Sheldon, AdminstratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required 1 Year inspection and met with Michelle Sheldon, Administrator.

LPA and Administrator toured the facility, 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 each has its own bathroom. Shower/bath is in a separate room available to clients per request. There is a supply of extra linens available for clients to use. Extra hygiene products and linens are available. The facility provides washers and dryers for client use; large loads like blankets are done by the facility in larger machines. Water temperature in clients' 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 to be clean. The dining room provides a hydration station with a variety of infused waters which has proven to be very popular with residents. 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 2, 2024. The facility has a hard wired sprinkler system. There are carbon monoxide detectors throughout the facility that are functional. The last disaster drill was conducted on 04/11/2024 and documented .

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 Michelle Sheldon is effective until 5/31/2025. Staff have proof of current First Aid/ CPR.

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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: 06/13/2024
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Continued from 809.....

Clients are allowed to leave facility but there is a curfew. Staff conducts health and wellness checks each and every hour, and there are protocols in place for missing clients.

No deficiencies found at the time of this inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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