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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800742
Report Date: 02/13/2023
Date Signed: 02/13/2023 11:09:40 AM


Document Has Been Signed on 02/13/2023 11:09 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:
496800742
ADMINISTRATOR:MARY A. KINGFACILITY TYPE:
740
ADDRESS:201 TAHOLA CT.TELEPHONE:
(707) 778-7711
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:11CENSUS: 9DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Mary KingTIME COMPLETED:
11:15 AM
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License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an annual required – 1 yr. Infection Control Inspection of the facility. LPA was welcomed by Licensee Mary King. There is a total of 9 residents, 1 with dementia, and 5 residents on Hospice.

Facility tour/inspection began at 10:00 AM:
LPA toured the facility on 2/13/2023 with Licensee Mary King; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be fully charged at the time of the visit. Facility Smoke and Carbon Monoxide detectors were found to be operational. There are night lights in common areas, resident’s bedrooms, and bathrooms of the facility. Hot water temperature measured between 114.6 degrees F and 117 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathroom faucets. Facility has two residents' bathroom with faucets that are motion sensor. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day. There are no special dietary needs for residents currently at the facility. Food is available for residents any time of the day. Toxins are stored in a locked room in garage. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Resident’s bedrooms have lighting & appropriate furnishing. Medications were centrally stored in a locked medication closet on the hallway by facility office. Disaster Drills have been conducted every 3 months with the last one being conducted on 12/20/2022.

Continue LIC 809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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: 496800742
VISIT DATE: 02/13/2023
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Infection Controle:

Facility has submitted a mitigation program plan and infection control plan. All staff, residents, & visitors check in with the electronic temperature log. Posters have been placed at facility. Facility has PPE supply stored in hallway closet and in garage. Staff had all PPE training required on file as well have been N95 Fit Tested.



LPA reviewed Licensing Information System (LIS) with Licensee who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1st Aid certification for staff.
Administrator Certificate is for Mary King # 6004998740 Exp. 3/1/2023
All staff have received COVID booster vaccinations and inclusively work at this facility.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 2/27/2023 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC809 (FAS) - (06/04)
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