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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803254
Report Date: 02/11/2025
Date Signed: 02/11/2025 11:01:49 AM

Document Has Been Signed on 02/11/2025 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 HOUSEFACILITY NUMBER:
126803254
ADMINISTRATOR/
DIRECTOR:
STEVENS,ANGELAFACILITY TYPE:
740
ADDRESS:1445 PARKWAY DRIVETELEPHONE:
(707) 464-3311
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY: 63TOTAL ENROLLED CHILDREN: 0CENSUS: 25DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Lucy JonesTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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At approximately 8:05AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Angela Stevens in the parking lot. She informed LPA she would not be able to stay as she had an appointment. LPA met with Business office manager Lucy Jones for the inspection. At approximately 8:30AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Facility has a backup generator to supply power in an emergency. Medication is centrally stored and secure. Activity supplies were plentiful and a schedule of activities was posted.
At approximately 9:00AM, LPA reviewed 8 resident records. Eight of eight records contained current and signed admission agreements, current physician reports and resident care plans. Medication records are thorough and contained physician's orders for each resident. At approximately 9:45AM, LPA reviewed 8 staff records. 8 of 8 records contained documentation of completed annual training as required. Evidence of current first aid and CPR training was current. At approximately 10:30AM, LPA reviewed the facility emergency disaster plan. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts and documents disaster drills Quarterly.

LPA received evidence of Liability insurance during this visit.



No citations issued during today's visit.
Bethany MoellersTELEPHONE: (707) 588-5040
Christopher ArnholdTELEPHONE: (707) 588-5084
DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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