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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803764
Report Date: 03/08/2023
Date Signed: 03/08/2023 02:22:29 PM

Document Has Been Signed on 03/08/2023 02:22 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:OUR HOUSEFACILITY NUMBER:
126803764
ADMINISTRATOR:SHANNON, ALEXANDERFACILITY TYPE:
735
ADDRESS:3309 MONTGOMERYTELEPHONE:
(707) 268-0679
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY: 4CENSUS: 4DATE:
03/08/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sara MeltonTIME COMPLETED:
12:00 PM
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At approximately 11:30AM, an informal virtual office meeting was conducted with this facility to discuss areas of concern with the operation of the facility. In attendance were Licensee Sara Melton, Administrator Alex Shannon, Licensing Program Manager (LPM) Bethany Moellers, Licensing Program Analyst (LPA) Chris Arnhold. Redwood Coast Regional Center was also represented by Quality Assurance Specialist Ronald Lee, Community Resource Manager Heather Odle and CMS Waiver & Employment Specialist Manager Sierra Braggs. During this meeting the following items were discussed:
-Records management
-Medication administration
-Staff Training
-Personal rights
-P&I money management and tracking
LPM Moellers discussed with Licensee the availability of the Departments Technical Support Services to provide additional assistance with the above mentioned areas of concern. LPM discussed the process to request an exception to allow locking a closet door to prevent damage to client clothing. The written request will be submitted to CCL by 03/24/2023.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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