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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803254
Report Date: 08/03/2023
Date Signed: 08/03/2023 09:53:23 AM

Unsubstantiated


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
07/14/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20230714151008
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: 36DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Allison FitchTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility staff did not meet resident's hygiene needs.
Facility staff did not empty resident's urine containers.
Facility staff did not ensure that resident was adequately hydrated.
INVESTIGATION FINDINGS:
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings from an investigation into the above allegations. LPA met with Executive Director Allison Fitch. Based on interviews conducted and records reviewed, R1's documentation shows they were able to conduct activities of daily living. Interviews conducted and documents reviewed showed staff conducted routine body checks during showers and ensured R1's clothing was laundered. R1's rights were respected when they refused showers and clothing options offered to them. Interviews conducted with staff showed urine containers were emptied when observed and when informed by R1. Interviews conducted showed staff routinely offer water and other beverages to residents throughout the day. Based on resident rights regulations, residents have the right to refuse liquids and staff do not force residents to take fluids. If staff notice residents continue to refuse, they contact the physician for instruction. 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: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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 4
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
07/14/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20230714151008

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: 36DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Allison FitchTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
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8
9
Facility staff did not ensure that resident's bedding was free of stains.
Facility staff did not attend to resident's bed sore.
Resident sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings from an investigation into the above allegations. LPA met with Executive Director Allison Fitch. Based on interviews conducted and records reviewed, facility housekeeping logs show R1 refused to have staff change their bedding on at least two occasions in July. When staff observe soiled areas, they clean or work with R1 to agree to change the bedding.
Based on interviews conducted and records reviewed, facility documention shows resident care notes observing redness on R1 and physician appointments being made. Ongoing documentation noted observations on the status of the injury. Facility staff ensured residents injury was addressed and documented status on an ongoing basis. Physician documentation could not determine whether the injury was pressure related or due to a fall. The notes also showed the injury was healing with no complications. Continued on LIC9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20230714151008
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: 08/03/2023
NARRATIVE
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Based on interviews conducted and records reviewed, facility observed and reported several falls sustained by R1. Facility reported to the physician and CCLD on the status of each fall and what injuries were sustained. Facility updated the care needs after each fall and continued documentation of their status. Facility documents any changes observed to residents appearance or status and reports to the physician.

This agency has investigated the above allegations. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20230714151008
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: 08/03/2023
NARRATIVE
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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: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4