<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800742
Report Date: 02/26/2024
Date Signed: 02/26/2024 02:57:45 PM


Document Has Been Signed on 02/26/2024 02:57 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: 11DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Mary King, Licensee/AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required visit of the facility. LPA was welcomed by staff Maria Botelho. Licensee Mary King was contacted by facility staff on the telephone and arrived later during this visit. There is a total of 11 residents, 5 dementia residents. There are 3 residents currently on Hospice.

LPA toured the facility on 2/26/2024 at 8:45 AM with staff, Licensee jointed shortly after; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 2/05/2024 at the time of the visit. Facility smoke detectors were found to be operational on 2/26/2024. LPA observed 2 out of 2 Carbon monoxide detectors that were found to be operational during the visit. There are night lights in many of the common areas, resident’s bedrooms, and bathrooms of the facility. Hot water temperature measured between 113.1 degrees F and 115.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 2/26/2024 at 9:15 AM. 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. LPA toured the kitchen area on 2/26/2024 at 9:15 AM with staff Maria and observed food stored in the refrigerator is labeled with dates. There are no special dietary needs for residents at the facility on 2/26/2024 at 9:20 AM. Food is available for residents any time of the day. At approximately 9:05 AM on 2/26/2024 LPA & Staff Maria observed unlocked spare medication cupboard containing 2 residents diarrhetic medications (see pic). Licensee immediately locked (see LIC809-D). Toxins are stored in a locked garage room. There was a supply of cleaners, hygiene products and paper products available for residents.

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


Document Has Been Signed on 02/26/2024 02:57 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: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review & interview, the licensee did not comply with the section cited above in 3 out of 5 staff (S1, S2, & S3) trainings on Postural supports, restricted condictions and health services & hospice care was not conducted for 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Licensee to submit reviewed written plan for staff training and how LPA will be able to verify training for all staff ; licensee to ensure that all staff receive required initial & ongoing training required by Health & Safety Code. Licensee to submit reviewed written plan for staff training, and how LPA will verify training to CCL by POC date of 3/8/2024
Type B
Section Cited
CCR
87705(c)(3)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review & interview, the licensee did not comply with the section cited above in 3 out of 5 staff (S1, S2 & S3) did not have required dementia training per regulations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Licensee to submit LIC9098 Proof of correction that staff S1, S2, & S3 have dementia training as required annualy to CCL by POC due date of 3/8/2024.
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: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


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: 02/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
in the facility at all times as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.”

A sample review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:30 AM on 2/26/2024 and learned that 5 of 5 residents have current physicians reports & care plans on file at this time as required by Title 22 Regulation. Hospice care plans were up to date for each hospice resident.



LPA conducted a sample review of staff records at 12:07 PM on 2/26/2024 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, 3 out of 5 Direct care staff have not received the additional training requirements as per Title 22 Regulations and H&S Code (see LIC809-D). LPA was presented with proof of CPR certification for staff although 3 out of 5 staff do not have First Aid certification (see LIC809-D)

Medications were centrally stored in a locked medication cabinet in the facility medication cabinet. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 2/26/2024 at 1:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is current and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted quarterly with the last one being conducted on 2/13/2024. Mary King Administrator Certificate # 6004998740 expires on 3/1/2025.



Appeal Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.
Continue to LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/26/2024 02:57 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: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411(c)(1)PERSONNEL REQUIREMENTS GENERAL; Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross.

This requirment is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
*Based on staff file review & interview the licensee failed to ensure that all staff has a current 1st aid certification in 3 of 5 staff which poses a potential Health & Safety to residents in care. On 2/26/2024 LPA reviewed staff files, & interview ass administrator, LPA learned that staff S1 S2, & S3 have either not renewed 1st Aid or there is NO 1st aid certification at this time.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Licensee to ensure that all staff have current first aid certifications at all times & at least one staff with CPR; Licensee to ensure that S1, S2, or S3 is not the only staff on duty or is a direct care staff until obtaining required 1st aid certification. Licensee to submit proof of 1st Aid Certif. for S1, S2 & S3. by POC due date 3/8/2024.
Type B
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...
:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observed unlocked kitchen medication cupboard containing 2 residents diarrhetic medications (see pic). housing centrally stored medications was left unlocked, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Licensee to administer staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Admin to submit LIC9098 self-certifying training completed. Admin to submit LIC9098 by Plan of correction due date of March 8, 2024 to CCL..
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: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


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: 02/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 3/15/2024:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Control of Property Grant Deed
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6