126803254-4-16-2024-21-AS-VBEI-D72SQ7-20240710140413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803254
Report Date: 04/16/2024
Date Signed: 04/16/2024 11:45:35 AM

Unfounded

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
04/08/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20240408125815

FACILITY NAME:	ADDIE MEEDOM HOUSE		FACILITY NUMBER:	126803254
ADMINISTRATOR:	ALLISON FITCH		FACILITY TYPE:	740
ADDRESS:	1445 PARKWAY DRIVE		TELEPHONE:	(707) 464-3311
CITY:	CRESCENT CITY	STATE: CA	ZIP CODE:	95531
CAPACITY:	63	CENSUS: 30	DATE:	04/16/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Angela Stevens		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Neglect/Absence of supervision

INVESTIGATION FINDINGS:

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At approximately 8:45AM, 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, (R1), had a history of non-payment and leaving the facility for several days. On 01/21/2024, staff entered R1's room and found the window screen was cut out and residents room key and pendant were on the bed. Staff searched the area and notified Law Enforcement of a missing person. R1 returned a few days later. This occurred a few more times. On 2/05/2024, R1 was observed by staff leaving the facility through the front doors. LPA reviewed residents record and found they were able to make their own decisions and paid for their own care. Continued on LIC9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

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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Control Number 21-AS-20240408125815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ADDIE MEEDOM HOUSE	FACILITY NUMBER: 126803254
	VISIT DATE: 04/16/2024

NARRATIVE

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R1 is able to leave the facility unassisted. Facility followed regulation and contacted Law Enforcement each time R1 did not return to the facility. Facility was in the process of requesting an updated physician report for R1 at the time of their departure. R1 was no longer a resident of this facility as of 02/05/2024.

This agency has investigated the above allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

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