496803856-10-16-2024-21-AS-VBEI-DAAR6V-20241022124522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803856
Report Date: 10/16/2024
Date Signed: 10/16/2024 03:34:22 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2024 and conducted by Evaluator Christi Coppo

COMPLAINT CONTROL NUMBER: 21-AS-20241008152519

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: 6	DATE:	10/16/2024
		UNANNOUNCED	TIME BEGAN:	01:37 PM
MET WITH:	Kathleen Albano, Administrator		TIME COMPLETED:	03:49 PM

ALLEGATION(S):

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Staff mismanaged medication
Personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christi Coppo conducted an unannounced visit and met with Administrator Kathleen Albano, Administrator. LPA came to the facility to open an investigation into complaint allegations listed above. Admin had to leave after interview with LPA. Admin gave caregiver permission to sign report.

During today's visit, LPA conducted interviews and made observations.

Complaint alleges personal rights. Complainant states they observed medication pill on the floor of facility, notified caregiver, and caregiver picked it up and put it in the kitchen drawer that stores the pre-poured medication. During investigation, LPA observed kitchen drawer that stores medication boxes to be empty, no pre-poured medications present. LPA interviewed Admin about medication allegation. Admin reported to LPA they know that pills on the floor have been a problem as some of the residetns put the pills in their pocket rather than taking them.

Continued on 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 21-AS-20241008152519

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/16/2024

NARRATIVE

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continued from 9099...

Admin explained that sometimes there are residents that just put their meds in their pocket rather than taking them. We sometimes see meds on the floor because the residents didn't put it properly in their mouth, but we dispose of it properly. Admin explained to LPA that they know the proper procedure for disposal, either take to pharmacy to destroy or put in water solution to dissolve and destroy, but some of the staff might have overlooked a pill on the floor. Admin indicated she has trained staff on how to properly dispose of contaminated medication pills. LPA and Admin discussed that going forward, caregivers and/or Med Techs staying with residents and witnessing them put the pills in their mouth and swallowing them. Based on LPA’s interview with Administrator, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Complaint alleges personal rights. Complainant states that there is a sliding lock present on the bottom of the front door preventing residents and visitors from entering or exiting without assistance from a staff member. LPA asked Admin about the lock present at the bottom of the front door. Admin advised that they are having trouble with a resident R1, several times R1 tried to elope. Admin explained that the addition of the lock is recent. R1 has had several sundowning episodes where they open the front door and want to get out. We try to redirect by giving activities, but redirecting does not always work. LPA advised that facility must be staffed such that there is adequate staff to both redirect and attend to the other residents. Admin understands and acknowledges re-directing is key. Caregiver immediately removed lock from bottom of door in LPA's presence. Based on LPA’s observation and interview with Administrator, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

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 caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with caregiver 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: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20241008152519

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/30/2024 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	87705 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...	1 2 3 4 5 6 7	Facility to train staff on medication management. Facility to submit staff training log for all facility staff by plan of correction due date.
	8 9 10 11 12 13 14	This requrement was not met by licensee as evidenced by: Based on LPA interview with Admin medication pills have been found on the floor of the facility, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 10/17/2024 Section Cited CCR 87705(l)(6)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (6 Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient	1 2 3 4 5 6 7	Facility removed lock in LPA's presence. Deficiency cleared.
	8 9 10 11 12 13 14	numbers to meet the care and supervision needs of all residents. This requriement was not met by licensee as evidenced by: Based on LPA interview and observation facility had sliding lock present on bottom of front door to address sundowning behavior and attempted elopment of resident..	8 9 10 11 12 13 14

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: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC9099 (FAS) - (06/04)

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