126803254-2-8-2024-21-AS-CARD-D29V59-20240208150733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 126803254
Report Date: 02/08/2024
Date Signed: 02/08/2024 03:07:55 PM

Document Has Been Signed on 02/08/2024 03:07 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 HOUSE		FACILITY NUMBER:	126803254
ADMINISTRATOR:	ALLISON FITCH		FACILITY TYPE:	740
ADDRESS:	1445 PARKWAY DRIVE		TELEPHONE:	(707) 464-3311
CITY:	CRESCENT CITY	STATE: CA	ZIP CODE:	95531
CAPACITY:	63	CENSUS: 30	DATE:	02/08/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Angela Stevens		TIME COMPLETED:	03:15 PM

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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced to continue the annual required inspection. LPA met with Administrator Angela Stevens.

At approximately 8:45AM, LPA reviewed 6 resident records. Six of six 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. LPA will follow up with Licensee regarding recent changes to the Admission agreement and the increase in the cost of care that were not submitted to the Department.

At approximately 10:45AM, LPA reviewed 6 staff records. 5 of 6 records did not contain documentation of completed annual training as required. Evidence of current first aid and CPR training were current. LPA and Administrator discussed staffing requirements throughout the building. Based on a review of resident records and staff schedules, LPA observed the facility does not have a sufficient number of staff to meet residents needs.

At approximately 12:30PM, LPA reviewed the facility emergency disaster plan. Facility has a generator to supply power during an outage. 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 conducted and documented a disaster drill in January 2024.

Continued on LIC 809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/08/2024

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While conducting this inspection, LPA followed up on an unusual incident report submitted by the facility on 12/26/2023. A staff member observed a resident waiting for their meal and gave the resident a plate containing turkey. The resident was allergic to turkey which was noted in the physician report and care plan. Facility contacted the physician and kept resident under observation. No ill effects were observed. Facility has implemented a new system in the kitchen for all staff to be aware of diet restrictions for each resident.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC309- Administrative Organization
LIC500- Personnel Report
LIC610E- Disaster Plan

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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and a record review, the licensee did not comply with the section cited above. Licensee updated the Admission agreement and costs to the levels of care and did not submit changes to the Department, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	Licensee to submit updated program plan, including but not limited to: Admission agreement, breakdown of levels of care, breakdown of the services provided for each level, staffing plan. Program plan to be submitted to CCL by POC date of 03/01/2024.

Type B

Section Cited

CCR

87211(g)

(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Previous Administrator left employment on 01/05/2024 and Licensee did not notified the Department within 30 days, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Licensee to submit Board Resolution, Qualifications and Administrator Certificate number to appoint the current Administrator. Documentation to be submitted to CCL by POC date 02/16/2024.

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: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(a)

Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. Facility has five residents that require two person assistance and did not ensure suffient staff were on duty to ensure needs were met, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2024
	Plan of Correction
1 2 3 4	Licensee will ensure facility has sufficient staff on duty to ensure residents needs are met. Licensee to submit the Daily staffing schedules on a daily basis to CCL to show evidence of suffient coverage. This POC will be ongoing beginning 02/09/2024.

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: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Five of Six staff records. The records did not contain evidence of initial or ongoing training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2024
	Plan of Correction
1 2 3 4	Licensee will submit a written plan describing the onboarding process of new employee's and how the facility will document initial and ongoing training. Plan to be submitted to CCL by POC date of 03/08/2024.

Type B

Section Cited

CCR

87555(b)(7)

General Food Service Requirements

(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Staff provided resident a food item they were allergic to. This posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2024
	Plan of Correction
1 2 3 4	Facility provided training for staff and updated how they keep track of special diets. POC cleared at time of visit.

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: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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