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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 03:34:43 PM

Substantiated


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
01/29/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240129105252
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):
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Staff does not ensure resident's needs are being met due to inadequate staffing.
Staff did not provide responsible party with changes of fee increases of resident's care plan.
INVESTIGATION FINDINGS:
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Administrator Angela Stevens, toured the building and reviewed records.
Based on records reviewed and interviews conducted, facility did not have a sufficient number of staff to meet the needs of residents. LPA addressed this concern on 02/08/2024 during the annual inspection. Since that date, facility has adjusted staffing levels to ensure they have staff sufficient to meet resident needs. Based on records reviewed and interviews conducted, facility sent notices to all residents and responsible parties on November 1, 2023 regarding an increase in care costs. The notice only informed them of their new rate, that would begin January 1, 2024. Residents and responsible parties were not advised of any other future additional costs. Continued on LIC9099-C
Substantiated
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)
Page: 1 of 5
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
01/29/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240129105252

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: DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Angela StevensTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not ensure resident's wheelchair foot rests are in place resulting in resident falling.
Resident sustained unexplained scratches while in care.
Staff does not ensure resident is properly cleaned.
Staff do not ensure incident reports are documented.
INVESTIGATION FINDINGS:
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Administrator Angela Stevens, toured the building and reviewed records.
Based on interviews conducted, LPA was not able to find evidence that residents wheelchair foot rests were not in place or that the lack of the rests caused a fall. LPA observed foot rests were in place during each visit to the facility. Based on records reviewed and interviews conducted, resident did sustain a scratch that was not immediately observed by staff. Upon discovery, staff provided first aid and notified responsible party and documented. Constant 1 on 1 supervision is not listed in any records reviewed. Resident does require 2 staff to assist with transfers and bathing.
Continued on LIC9099-C...
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)
Page: 2 of 5
Control Number 21-AS-20240129105252
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: 04/04/2024
NARRATIVE
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LPA reviewed records regarding resident care. LPA observed staff complete a full body/skin check every few days to ensure changes in condition are captured. Based on interviews conducted, staff will assist residents with hand washing before meals, but sometimes residents will soil their hands again without staff notice.
LPA reviewed facility documentation regarding staff observations. Facility uses progress notes for each resident to document and track healing injuries or changes of condition, Body/skin check forms to document changes of condition, Communication logs to pass information between staff and incident reports that are created for Licensing. Facility staff are trained to document things when they are observed.

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.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240129105252
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: 04/04/2024
NARRATIVE
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Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Administrator and Appeal rights were given.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20240129105252
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
HSC
1569.655(a)
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(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior
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Licensee to send an updated notice to all residents and responsible parties of the new rate structure, including but not limited to, all potential fees or charges they may be subject to while residing at the facility. Notice to be
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written notice...the reason for the increase, and a general description of the additional costs. This requirement is not met as evidenced by:Licensee did not notify residents of a Hospice fee. This poses a potential personal rights risk to residents.
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sent to all families and CCL by POC date of 05/03/2024.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5