496800742-8-21-2025-21-AS-BMOS-DKVTQL-20250825145604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800742
Report Date: 08/21/2025
Date Signed: 08/21/2025 02:48:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/06/2025 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20250506133955

FACILITY NAME:	OUR HOUSE		FACILITY NUMBER:	496800742
ADMINISTRATOR:	MARY A. KING		FACILITY TYPE:	740
ADDRESS:	201 TAHOLA CT.		TELEPHONE:	(707) 778-7711
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	11	CENSUS: 9	DATE:	08/21/2025
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Mary King, LIcensee/Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff caused injury to resident in care
Staff did not seek medical attention for resident in care
Staff worked at the facility while under the influence of drugs
Staff did not report resident incidents to appropriate parties

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegations listed above. LPA met with Licensee, Mary King.

Complainant alleges on 4/27/25 staff (S1) inserted fingers in resident’s (R1) anus to un-impact due to being constipated, causing redness/bruising and bleeding and on 5/4/25 R1 was still bloody and irritated and alleges S2 claimed tried calling physician, but there was no documentation. During the course of the investigation LPA conducted interviews with 4 staff, hospice nurse, and obtained law enforcement report, medical records, and hospice reports. Review of R1’s medical records indicate can toilet self (is continent of bowel & bladder), very independent of ADL’s. Interview with hospice nurse revealed on 5/7/25 Hospice received call from R1’s family who had received a call from outside party indicating R1 was impacted and bleeding out of anus and went to the ER /hospital and then to Post Acute facility.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250506133955

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 496800742
	VISIT DATE: 08/21/2025

NARRATIVE

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Continued from LIC9099

Hospice personnel arrived same day and confirmed R1 was not sent out and was not experiencing a medical emergency at time of visit. The department did not receive LIC624 (incident report) due to R1 not being taken out for medial attention. LPA obtained police incident investigation report which did not reveal any information to support the allegations. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation’s Staff caused injury to resident in care, Staff did not seek medical attention for resident in care, & Staff did not report resident incidents to appropriate parties are UNSUBSTANTIATED.

Staff worked at the facility while under the influence of drugs- RP states that on 4/26/25 staff (S1 & S2) were drunk while working at the facility. RP states S1 and S2 smelled like alcohol and S1 was slurring words. And alleges on 4/6/25 and 4/13/25, S4 arrived at the facility with red eyes, disheveled, and had a strong smell of marijuana. LPA conducted 5 staff interviews which revealed previous staff may have been terminated due to violating facility policies. No information was obtained to support the staff named involved in the allegation were under the influence while working. Investigation revealed conflicting information from staff investigations without any other corroborating evidence. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff worked at the facility while under the influence of drugs is UNSUBSTANTIATED.

A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

LIC9099 (FAS) - (06/04)

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