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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803254
Report Date: 03/03/2025
Date Signed: 03/03/2025 03:32:19 PM

Document Has Been Signed on 03/03/2025 03:32 PM - 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: DATE:
03/03/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Angela StevensTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At approximately 2:30PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a special incident report submitted to the Department on 02/18/2025. LPA met with Executive Director Angela Stevens and reviewed records. The incident was in regards to a staff member accidentally pouring urine, from a juice bottle, into a cup for a resident during a medication pass. This facility does not utilize a medication cart during medication pass. The Medication technician bring medication to each residents room. The medication technician entered the residents room to assist with medications and observed several bottles of juice on the counter top. The resident had recently received the juice from a family member. The medication technician poured what appeared to be apple juice from one of the open bottles and gave it to the resident. Resident took the medication and drank the liquid. Resident told staff that the liquid was their urine. Based on records reviewed, resident lives in the assisted living section of the building and does not have a dementia diagnosis. There were no prior incidents where resident used a bottle to urinate in. Staff immediately removed the bottles from the residents room. Resident responsible person was notified. Facility placed resident on alert charting and updated their care plan.

No citations issued during todays visit.
Bethany MoellersTELEPHONE: (707) 588-5040
Christopher ArnholdTELEPHONE: (707) 588-5084
DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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