496803856-9-21-2023-21-AS-MCUA-CVVUW2-20230921155602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803856
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:56:10 PM

Document Has Been Signed on 09/21/2023 03:56 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 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:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Kathleen & George Albano (Administrator)		TIME COMPLETED:	04:10 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	Licensing Program Analysts (LPAs) Cuadra and Coppo conducted an unannounced required annual visit and met with Administrator Kathleen & George Albano. There are 6 residents in care some with a diagnosis of dementia and receiving hospice services. Required postings were observed. LPA/Administrator toured the building and grounds which was found to be clean and in good repair. Passageways were observed unobstructed. Residents' rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Hot water temperature in bathrooms used by residents measured at 105.3 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Fire extinguisher was last serviced September 13, 2022. Smoke detectors and carbon monoxide detector are hardwired and fire door located in the hallway were tested and properly working. Last disaster drill conducted on 6/10/23. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Administrator Certificate for Kathleen Albano, 6050072740, expires on 6/7/24. Medications were reviewed, centrally stored and locked. A spot check of medications revealed that centrally stored medications log has discrepancies and an omission of dates filled and prescription number. LPA initiated file review at 1:00 pm. LPA reviewed six residents files and five staff files. All residents files do have a current medical assessment. However, care plans for 3 out of 6 (R1, R2 & R3) residents were not signed by their responsible party within the last 12 months. Also, 2 out of 5 (S1 & S2) staff records do not have current First Aid/CPR certificates and 4 out of 5 staff records needs(S1, S2, S3 & S4) additional 20 hours of required training. Licensee agreed to submit updates of the following documents by 10/12/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) & Copy of Liability Insurance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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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Document Has Been Signed on 09/21/2023 03:56 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 HOME LLC	FACILITY NUMBER: 496803856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs record review, the licensee did not comply with the section cited above in [2] out of [5] staff CPR/training records were not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training records within 3 weeks. POC due date is 10/12/2023

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above in [3] out of [6] care plan for residents (R1, R2 & R3) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide signed copies of residents' Appraisal Needs and Services Plans within 3 weeks. POC due date is 10/12/2023.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2023 03:56 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 HOME LLC	FACILITY NUMBER: 496803856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	A spot check of medications revealed that centrally stored medications log has discrepancies and one omission of dates filled and prescription numbers.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee agreed to review the centrally stored medication log and maintain an accurate log going forward. Also, licensee will submit a written statement plan of how they plan to prevent this in the future. POC due date is 10/12/2023

Type B

Section Cited

CCR

87203

87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above in [2] out of [3] fire extinguishers which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee needs to provide proof of serviced fire extinguishers by plan of correction due date, POC due date is 10/12/2023

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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