216804183-4-4-2024-21-AS-SHAN-D3ZRKJ-20240404130536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804183
Report Date: 04/04/2024
Date Signed: 04/04/2024 01:05:44 PM

Document Has Been Signed on 04/04/2024 01:05 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 LIVING		FACILITY NUMBER:	216804183
ADMINISTRATOR:	MUELRATH, KELLY		FACILITY TYPE:	740
ADDRESS:	40 MEADOW WAY		TELEPHONE:	(707) 799-1557
CITY:	SAN GERONIMO	STATE: CA	ZIP CODE:	94963
CAPACITY:	6	CENSUS: 2	DATE:	04/04/2024
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kelly Muelrath, Administrator		TIME COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Shannan Hansen made an unannounced post-licensing inspection of this licensed senior care facility at approximately 8:30AM. LPA met with Administrator Kelly Muelrath. The facility currently has 2 residents, one with dementia diagnosis, none receiving hospice services.

At approximately 8:45AM LPA toured the building and grounds which were found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity space & activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezers were clean, and food was stored properly. Toxins are stored in locked closet across from laundry room & in locked cabinets under kitchen-sink. Water temperature measured 112.8 degrees F & 114.9 degrees F, within regulations of 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers were last inspected 1/26/2024 & charged. 6 smoke detectors were found to be in working order, 2 carbon monoxide detectors were present and operational. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

At approximately 10:15 AM, LPA reviewed 2 resident records and found 2 of 2 residents have current physician's reports & care plans. 2 of 2 resident records contained current and signed admission agreements and medication records are thorough and contained physician's orders for each resident.

At approximately 11:20 PM, LPA reviewed 5 staff records. All records contained documentation of completed training as required. Evidence of current first aid and CPR training were present.

At approximately 12:50PM, LPA reviewed the facility emergency disaster plan with staff. 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.
Continued on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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: MEADOW CREEK SENIOR LIVING	FACILITY NUMBER: 216804183
	VISIT DATE: 04/04/2024

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Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts and documents disaster drills quarterly & in different shifts with the last being 2/2024. Administrator Certificate’s for Kelly Muelrath # 6067128740 Exp. 9/26/2025.

The back porch of the house is shaded and provides a safe and secure area for residents to spend time outside.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 4/30/2024 to CCL:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 9020 Register of Facility Resident’s

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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