496803856-8-2-2024-21-AS-CCOO-D7RU26-20240802151124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803856
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:11:52 PM

Document Has Been Signed on 08/02/2024 03:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	OUR HOME LLC		FACILITY NUMBER:	496803856
ADMINISTRATOR:	ALBANO, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	2364 MELBROOK WAY		TELEPHONE:	(707) 527-9390
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 5	DATE:	08/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Administrator Kathleen Albano		TIME COMPLETED:	03:26 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) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Kathleen Albano arrived later. Facility contact information was reviewed. At approximately 9:30am LPA and caregiver toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food in refrigerator had open items covered but not labeled with date of opening/storing. Food observations include: refrigerator drawer of radishes were covered in black substance and spots. Refrigerator drawer liner covered with black spots of a black substance and contained wilted and browning celery with brown liquid, and lemon and orange with white and blue fuzzy substance (deficiency cited, see 809D). LPA discussed with Admin their practice of freezing milk. LPA observed frozen milk to be stamped with a best if used by date that has expired by one day. LPA advised to keep fresh milk on hand or if they must freeze the milk to please defrost and use by best if used by date. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 106.8.and 111.3 degrees F which is within the allowable range of 105 to 120 degrees F. One [1] of two [2] main bathrooms had cabinet containing toxins not was locked but had locking function (deficiency cited, see 809D). LPA inspection of garage revealed a walled off storage room used as a sleeping area for staff and included fan, bed, and stereo. LPA advised Admin they can either submit a LIC200 with an updated facility sketch to CCL to request fire clearance for the room, or remove all items from that room and cease have any staff use it. Continued on 809C...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOME LLC	FACILITY NUMBER: 496803856
	VISIT DATE: 08/02/2024

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

Continued from 809...

as a sleeping quarter. Admin chose to remove all items from storage room in garage and cease using it as a sleeping quarter. Admin to submit pictures of storage room with all personal sleeping items removed to CCL by 8/9/2024.

Fire extinguishers were last inspected 9/21/2023. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 4/11/2024. LPA advised that emergency drills must be performed every quarter. Facility has a backup generator for use during a power outage.

At approximately 11:00am LPA conducted a review of five [5] out of [5] resident records. R1 has diagnosis of dementia, but most recent physician's report dated 5/15/2023 did not have all pages present, last page with doctor signature line not present, the next most current physician's report dated 2020. R1's most recent appraisal dated 5/5/2023 (deficiency cited, see 809D). Half rails present on five [5] out of [5] resident beds, however none had doctor's order on file.

At approximately 12:30pm LPA conducted review of 5 staff records. S1 did not have fingerprint clearance. Per Admin, S1 was present at the facility on 7/25/2024 and was in training. Per Guardian, the fingerprint clearance status of S1 is "in process," but not yet showing a clearance determination of eligible (deficiency cited, see 809D). LPA advised Admin that S1 may not be present at or working in the facility, whether training or working, until fingerprint clearance is obtained and Guardian shows S1 with a clearance determination of eligible. S2 did not have current training completed (deficiency cited, see 809D). S3 did not have a Health Screen on file, however TB clearance via chest xray was on file.

At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies cited.

Administrator Kathleen Albano Administrator Certificate 7017523740 expires 6/7/2026. All fees are current as of this time.

Continued on 809C(2)...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOME LLC	FACILITY NUMBER: 496803856
	VISIT DATE: 08/02/2024

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

Continued form 809C...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiences within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

Page: 3 of 11

Document Has Been Signed on 08/02/2024 03:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOME LLC	FACILITY NUMBER: 496803856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA interview with Admin and LPA record review, the licensee did not comply with the section cited above in that S1 did not have fingerprint clearance. Per Guardian, the fingerprint clearance status of S1 is "in process," but not yet showing a determination of eligible clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	Facility to submit LIC 9098 self-certifying that S1 will not be present at or working in the facility, whether training or working, until fingerprint clearance is obtained and Guardian shows S1 with a clearance determination of eligible.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

Page: 4 of 11

Document Has Been Signed on 08/02/2024 03:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOME LLC	FACILITY NUMBER: 496803856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.626(a)

Other Provisions

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin record review, the licensee did not comply with the section cited above in that S2 did not have current training completed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Facility to submit to CCL training log for S2 showing all 20 hours of required training completed by plan of correction due date.

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA, caregiver, and Admin observation, the licensee did not comply with the section cited above in that refrigerator drawer of radishes were covered in black substance and spots. Refrigerator drawer liner covered with black spots of a black substance and contained wilted and browning celery with brown liquid, and lemon and orange with white and blue fuzzy substance, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	Facility threw away all identified items and removed drawer liner with LPA present. Deficiency cleared.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

Page: 5 of 11

Document Has Been Signed on 08/02/2024 03:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOME LLC	FACILITY NUMBER: 496803856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1 has diagnosis of dementia, but most recent physician's report dated 5/15/2023 did not have all pages present, last page with doctor signature line not present, the next most current physician's report dated 2020. R1's most recent appraisal dated 5/5/2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Facility to submit pictures to CCL of current physician's report with all pages present and doctor's signature present by plan of correction due date. Facility to submit to CCL current appraisal for R1 by plan of correction due date

Type B

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that one [1] of two [2] main bathrooms had cabinet containing toxins not locked but had locking function, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Facility to train all staff on proper storage of toxins and disinfectants and submit to CCL copy of training log by plan of correction due date.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

Page: 6 of 11