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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800742
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:58:26 PM

Document Has Been Signed on 03/20/2025 03:58 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/
DIRECTOR:		MARY A. KINGFACILITY TYPE:
740
ADDRESS:201 TAHOLA CT.TELEPHONE:
(707) 778-7711
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 11TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Deanda Start, DesigneeTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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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 but unavailable for today’s visit and sent Designee, Deanda Start, who arrived shortly after. There is a total of 10 residents, 5 with a dementia diagnosis. There are 3 residents currently on Hospice, facility has a Hospice waiver approved for 6. Facility is single story with 10 bedrooms & 4 Bathrooms. Petaluma Fire Department has granted clearance for 11 Non-ambulatory residents, 3 of which can be bedridden in rooms 5, 7, & 11.

LPA toured the facility on 3/20/2025 at approximately 9:30 AM with staff, Designee joined shortly after; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The 3 Fire Extinguisher were found to be last charged on 1/20/2025 at the time of the visit. Facilities smoke & Carbon monoxide detectors were found to be operational on 3/20/2025. There are night lights in many of the common areas, resident’s bedrooms, and bathrooms of the facility. Extra hygiene products and linens were available. Resident bathrooms had required slip resistant mats and grab bars. Hot water temperature measured between 111.5 degrees F and 113.9 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 3/20/2025 at 9:35 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 3/20/2025 at 9:15 AM with staff Maria and observed food stored in the refrigerator is labeled with dates. There are special dietary needs for residents at the facility on 3/20/2025 and documented. Food is available for residents any time of the day. Toxins are stored in a locked garage closet & hallway closet. There was a supply of cleaners, hygiene products and paper products available for residents.

Continue to LIC809-C

Bethany MoellersTELEPHONE: (707) 588-5026
Shannan HansenTELEPHONE: 707-588-5026
DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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: 03/20/2025
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Continued from LIC809

At 10:30 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 3/20/2025 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 11:30 PM on 3/20/2025 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, 5 out of 5 direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was also presented with proof of CPR/First Aid certification for 5 out of 5 staff requiring.

Medications were centrally stored in a locked medication cabinet in the facility dining room & in locked hall closet adjacent to office. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 3/20/2025 at 12:15 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

Disaster Drills have been conducted quarterly with the last one being conducted on 12/13/2024. Facility has food supply for emergencies and generators if they lose power. Mary King Administrator Certificate # 6004998740 expired on 3/1/2025, LPA was presented with proof of trainings for new certificate.



No deficiencies observed during today's inspection.
LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 3/28/2025:
LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changed)
LIC 9020 Register of Facility Client’s/Resident’s
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: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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