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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803856
Report Date: 08/20/2025
Date Signed: 08/20/2025 04:20:37 PM

Document Has Been Signed on 08/20/2025 04:20 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 LLCFACILITY NUMBER:
496803856
ADMINISTRATOR/
DIRECTOR:		ALBANO, KATHLEENFACILITY TYPE:
740
ADDRESS:2364 MELBROOK WAYTELEPHONE:
(707) 527-9390
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 5DATE:
08/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Kathleen Albano, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator/licensee Kathleen Albano arrived later. Administrator certificate #7017523740 expires 6/7/26. Facility roster and contact information was reviewed.

At approximately 10:00am LPA and licensee 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 was found to be stored in a safe manner with open items covered. Cleaning supplies and sharp knives located in locked closet. During tour of facility, licensee and LPA observed butcher knife left unattended on kitchen island with residents present less than 2 feet away at dining table (deficiency cited, see 809D). During tour LPA observed ring camera video surveillance in common areas of facility as well as outside in backyard and at front door. Licensee confirmed that cameras have audio. LPA advised cameras cannot have audio as that is a personal rights violation. LPA advised that video surveillance can be present in common areas as long as the surveillance has been disclosed to residents and/or their responsible party, however the surveillance cannot include audio (deficiency cited, see 809D)

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 94.5 in bathroom between rooms #4 and #5 and 102.9 degrees F in bedroom #3 which is not within the allowable range of

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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OUR HOME LLC
FACILITY NUMBER: 496803856
VISIT DATE: 08/20/2025
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105 to 120 degrees F. But water temperatures measured at 106.6 degrees F in bathroom by room #2, and 111.7 degrees F in the kitchen which is within the allowable range of 105 to 120 degrees F. Licensee advised due to facility having 2 water heaters water has to be turned on in the laundry room in order to get hot in those rooms measuring out of regulation. LPA advised water must be hot within a reasonable amount of time, at least within 2-3 minutes of hot water being turned on. LPA discussed with licensee that a resident is not going to know or even have access to the laundry room in order to turn the water on so that they can get hot water to come out of faucet (deficiency cited, see 809D).


Per licensee, facility has a plan to complete an expansion, but construction has not started as they have not received building permit. Licensee and drafter of blueprints went to the city of Santa Rosa's Building Permit building and showed the preliminary sketches, but that is as far as they have gotten in the process. LPA advised that LPA has concerns of potential disruption to residents in care, due to noise that this project could cause. LPA requested written plan to be submitted to CCL prior to start of the expected construction along with copy of building permit from the City of Santa Rosa. The written plan should address how the facility will ensure the health and safety of residents in care while the construction occurs, as well as materials and equipment handling to ensure they are inaccessible to residents in care. Staff will be required to continuously remind and check all residents to make sure that they are not going to the construction site and notify their responsible parties. Facility would like capacity increase from 6 to 9 residents after expansion complete. LPA advised once fire clearance is granted LPA will return to facility to complete inspection for capacity change.

Fire extinguishers were last inspected 9/30/24. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 8/15/25. Facility has a backup generator for use during a power outage.

At approximately 12:00pm LPA conducted review of five [5] staff records. All required documentation present. However, LPA and licensee discussed training materials. LPA and Admin discussed number of hours reported in one day for training. Licensee clarified that she does not complete the training all in one



Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OUR HOME LLC
FACILITY NUMBER: 496803856
VISIT DATE: 08/20/2025
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day, but spreads it out over the entire year. LPA and licensee discussed using updated materials, published within the decade, so as to provide the most current information regarding dementia care. LPA will send licensee link of approved training vendors and licensee will determine if she will continue conducting her own training or instead use an approved vendor.

At approximately 1:00pm LPA conducted a review of five [5] resident records. All required documentation present. 1/2 rail orders all 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. LPA and licensee discussed the maintenance and requirements of a PRN MAR and that it must include the date and time given, the dosage, and the outcome or resident response. LPA discussed with licensee important components of maintaining the Centrally Stored Medication log (CSML). She must maintain current physician's orders and those orders must match what is written on the CSML and the information on the prescription bottle must also match what is recorded on the CSML. LPA and licensee did spot check of Quetiapine for R1. Per prescription and CSML, quantity of pills was 90. Date started was 7/20/25. R1 takes one pill daily at bedtime. So, total remaining in bottle should have been 59 pills. However, LPA and licensee got count of 37 pills (deficiency cited, see 809D).

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

Liability Insurance

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 deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 04:20 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/20/2025 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOME LLC
FACILITY NUMBER: 496803856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation and interview, the licensee did not comply with the section cited above in that video survelliance with audio was found in the common areas inside and outside the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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Facility immediately removed all cameras from inside and outside of facility, except for ring camera on front door. Licensee agrees to disable audio from front door ring camera. Facility to submit written notification to all residents and responsible parties disclosing the use of common area video surveillance Facility ti submit copies of notifcation to CCL by plan of correction du date. Facility to submit LIC9098 ensuring all video surveillance does not include audio, by plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 04:20 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/20/2025 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOME LLC
FACILITY NUMBER: 496803856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation and record review, the licensee did not comply with the section cited above in that count of Quetiapine for R1 did not match Centrally Stored Medication Log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
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Licensee to submit plan to train all employees that administrering medication. Medication training must include medication test as required per Health and Safety Code 1569.69. Training to be conducted no later than 9/3/25 and training log and/or certificates of completion to be submitted to CCL no later than 9/2/25. LPA will return at later date to perform meication check.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 04:20 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/20/2025 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OUR HOME LLC
FACILITY NUMBER: 496803856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to residents in care measured at 94.5 in bathroom between rooms #4 and #5 and 102.9 degrees F in bedroom #3, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2025
Plan of Correction
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Licensee to consult with professional plumber as to how best to regulate water temperature so that water comes up to a hot tempertaure within regulation within a timely manner. Licensee to report to LPA recommedations and what oprtion they will choose in order to regulate temperature. LPA will return to measure water temperature once repair/replacement has been compelted.
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation, the licensee did not comply with the section cited above in that licensee and LPA observed butcher knife left unattended on kitchen island with residents present less than 2 feet away at dining table which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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Licensee immeidately locked up butcher knife while 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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