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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803254
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:33:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/01/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240201111036
FACILITY NAME:ADDIE MEEDOM HOUSEFACILITY NUMBER:
126803254
ADMINISTRATOR:ALLISON FITCHFACILITY TYPE:
740
ADDRESS:1445 PARKWAY DRIVETELEPHONE:
(707) 464-3311
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY:63CENSUS: 31DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Angela StevensTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulting in resident’s fall.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegation. LPA met with Administrator Angela Stevens, toured the building and reviewed records. Based on interviews conducted and records reviewed, resident was found on the floor of their room after falling. Interview with staff revealed they were assisting another resident when the fall occurred. The resident was discovered shortly after the fall and staff assisted them. LPA reviewed staffing records for the time in question and found facility had sufficient staff at the time. Based on records reviewed, resident did not sustain injury and was found shortly after the incident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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