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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803254
Report Date: 02/17/2023
Date Signed: 02/17/2023 12:23:55 PM


Document Has Been Signed on 02/17/2023 12:23 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:ALLISON FITCHFACILITY TYPE:
740
ADDRESS:1445 PARKWAY DRIVETELEPHONE:
(707) 464-3311
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY:63CENSUS: 34DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Allison FitchTIME COMPLETED:
10:00 AM
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Administrator Allison Fitch.

Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Toxins are stored and not accessible. There was a supply of cleaners, hygiene products and paper products available for resident use.

Facility has submitted an infection control plan. Posters are in place at the entrance and throughout the building. Facility has PPE supplies. Medications are secure and not accessible to residents. All staff had masks on during this visit.


There were no deficiencies found in the areas inspected.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
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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