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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800742
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:15:26 PM


Document Has Been Signed on 05/30/2023 02:15 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:
496800742
ADMINISTRATOR:MARY A. KINGFACILITY TYPE:
740
ADDRESS:201 TAHOLA CT.TELEPHONE:
(707) 778-7711
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:11CENSUS: 10DATE:
05/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Mary King, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management- incident inspection regarding a medication error. LPA met with Licensee/Administrator Mary King.

LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 05/15/2023 of a medication error. The errors occurred on 05/12/2023 and 05/13/2023 when staff prepoured medication with PRN (as needed pain medication) for resident (R1), (See LIC809-D). Responsible party and prescribing physician were notified of the medication error. LPA obtained copies of Physician Report and Medication Assessment Record (MAR) for the month of May 2023 for R1.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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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Document Has Been Signed on 05/30/2023 02:15 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2023
Section Cited
CCR
87465(a)(5)

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87465(a)(5) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed
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Licensee to submit plan of correction for medication training to CCL by 5/31/2023. Licensee to submitt signed and dated training with all staff that pass medication by 6/9/2023.
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Based off self-reported incident report and interview with consulting Administrator and Licensee on 5/30/2023, the care staff over medicated the resident on pain medications that were, as needed but prepoured with regular medications. This is an immediate health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
LIC809 (FAS) - (06/04)
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