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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803254
Report Date: 10/14/2021
Date Signed: 10/14/2021 02:35:54 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:ADDIE MEEDOM HOUSEFACILITY NUMBER:
126803254
ADMINISTRATOR:COLLINS, JENNIFERFACILITY TYPE:
740
ADDRESS:1445 PARKWAY DRIVETELEPHONE:
(707) 464-3311
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY:63CENSUS: 32DATE:
10/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Allison FitchTIME COMPLETED:
02:45 PM
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At approximately 12:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an incident report and a suspected elder abuse report, (SOC341) submitted by the facility. LPA met with Administrator Allison Fitch, toured the facility and reviewed records. The incident involved a resident who refused to cooperate with staff and then became assaultive. While resident was assaulting staff, staff attempted to defend themselves which resulted in some bruising and a small skin tear on residents wrist. Staff member received multiple bruises on the arms from defending the assault. LPA reviewed resident records and found numerous incidents where resident was assaultive with both staff and other residents. In each incident, facility notified responsible parties and adjusted resident care plan to address the behaviors. There are ongoing communications with responsible parties to locate a more appropriate level of care for resident. LPA reviewed staff training records and found staff received training on 08/25/2021, on Dementia residents and how to deal with this sort of behavior.
Based on information received during this visit, facility followed regulation and training in dealing with a combative resident. LPA requested another refresher training for staff, to ensure continued compliance.

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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