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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804183
Report Date: 11/21/2023
Date Signed: 11/21/2023 05:38:57 PM


Document Has Been Signed on 11/21/2023 05:38 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:MEADOW CREEK SENIOR LIVINGFACILITY NUMBER:
216804183
ADMINISTRATOR:MUELRATH, KELLYFACILITY TYPE:
740
ADDRESS:40 MEADOW WAYTELEPHONE:
(707) 799-1557
CITY:SAN GERONIMOSTATE: CAZIP CODE:
94963
CAPACITY:6CENSUS: 0DATE:
11/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kelly Muelrath, Licensee/AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Hansen conducted a pre-licensing inspection and met with Administrator Kelly Muelrath. Fire clearance has been approved for 6 non-ambulatory residents by Marin County Fire Department. LPA will conduct a component III orientation with Administrator Kelly Muelrath. Facility has a dementia care program and a request for hospice waiver for 2.

LPA toured facility and observed: Facility is a one floor residence in good repair and at a comfortable temperature. Hot water temperature checked 115.5 degrees F to 115.7 degrees F in 2 out of 2 resident's bathrooms as required by Title 22 Regulations and Fire Extinguisher is fully charged. Smoke and Carbon Monoxide detectors present and in working condition. The facility has a phone line designated for resident’s use. There is an ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Personnel and residents' records will be stored in locked front hallway cabinet. Centrally stored medications will be kept in locked kitchen cabinet. Facility plans on having awake staff.

The facility has three resident’s bedrooms and two bathrooms. Facility has a kitchen, laundry room, living room area, office, dining room. Facility plans on having several different activities available for residents as desired. There is outdoor deck space for activities and visiting. Resident's & Personnel records, medication, first aid supplies, and toxins will be locked. Postings noted to be current and in compliance with guidelines. Locked box for sharps in kitchen and cleaning/laundry supplies in locked cabinet in laundry room. First aid kit was observed. Emergency supplies and PPE located in kitchen cabinet and container to be stored. All exits have egress alarms. Infection Control Plan has been submitted. Inspection conducted and report generated in office and signature obtained off site. Licensee does not anticipate opening prior to January 7, 2024.

Facility is cleared for licensure.
No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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