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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803856
Report Date: 07/27/2021
Date Signed: 07/27/2021 03:13:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:OUR HOME LLCFACILITY NUMBER:
496803856
ADMINISTRATOR:ALBANO, KATHLEENFACILITY TYPE:
740
ADDRESS:2364 MELBROOK WAYTELEPHONE:
(707) 527-9390
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 6DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator, Kathleen AlbanoTIME COMPLETED:
03:20 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
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct an Annual inspection at approximately 2:15 PM, and met with administrator Kathleen Albano. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in by administrator. Hand sanitizing was requested upon entry. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with administrator and observed COVID postings throughout. Staff were observed to be wearing face masks. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training and been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed administrator has necessary PPE and supplies to support a resident in isolation.

Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked closet. A 30 day supply of medications are stored in a locked closet, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) located in garage. Exit alarms on exit doors were working properly.

Continued on LIC809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: OUR HOME LLC
FACILITY NUMBER: 496803856
VISIT DATE: 07/27/2021
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
Facility is allowing residents to have meals in the dining room. All staff and visitors are required to wear masks and visitation is happening primarily on outdoor patio area.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2