126803254-6-30-2022-21-AS-BMOS-CHDV44-20220817160544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803254
Report Date: 06/30/2022
Date Signed: 06/30/2022 12:33:53 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
06/08/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20220608144646

FACILITY NAME:	ADDIE MEEDOM HOUSE		FACILITY NUMBER:	126803254
ADMINISTRATOR:	COLLINS, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1445 PARKWAY DRIVE		TELEPHONE:	(707) 464-3311
CITY:	CRESCENT CITY	STATE: CA	ZIP CODE:	95531
CAPACITY:	63	CENSUS: 35	DATE:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Angela Stevens		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's toilet is filthy

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to complete the investigation into the above allegation. LPA met with Health Service Director Angela Stevens, toured the facility and reviewed records. Based on interviews conducted and records reviewed, Housekeeping staff failed to clean several resident rooms for approximately 2 weeks. The error was corrected and housekeeping staff were retrained on the frequency of room cleaning.
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is 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 Angela Stevens and Appeal rights were given.

Substantiated

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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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 3

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
06/08/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20220608144646

FACILITY NAME:	ADDIE MEEDOM HOUSE		FACILITY NUMBER:	126803254
ADMINISTRATOR:	COLLINS, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1445 PARKWAY DRIVE		TELEPHONE:	(707) 464-3311
CITY:	CRESCENT CITY	STATE: CA	ZIP CODE:	95531
CAPACITY:	63	CENSUS:	DATE:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Angela Stevens		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not following COVID protocols
Staff are not meeting resident's laundry needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to open an investigation into the above allegations. LPA met with Health Service Director Angela Stevens, toured the facility and reviewed records. Based on interviews conducted and records reviewed, facility has been following covid policies with visitors to the facility. Sign in logs are present at front door along with thermometer to record temperatures. Vaccination and testing documentation is recorded for each visitor. LPA was informed by staff that there have been times when a visitor gets past without signing in. Laundry is done as needed for each resident but at least once a week. Facility documents the date laundry is washed, dried, folded and put away. LPA was informed there are times when the log is not filled out.
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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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 3

Control Number 21-AS-20220608144646

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: 06/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/01/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on interviews and records reviewed,	1 2 3 4 5 6 7	Licensee to ensure the facility is clean and in good repair at all times. Housekeeping staff were retrained on cleaning duties and resident was provided a new toilet. POC Cleared at time of visit.
	8 9 10 11 12 13 14	Licensee did not ensure resident toilets were cleaned as needed. This poses a potential health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3