<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803625
Report Date: 12/12/2022
Date Signed: 12/12/2022 11:09:49 AM

Document Has Been Signed on 12/12/2022 11:09 AM - 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:MENDO HOUSEFACILITY NUMBER:
236803625
ADMINISTRATOR:HIRE, BRANDONFACILITY TYPE:
735
ADDRESS:1116 WEST PERKINS STREETTELEPHONE:
(707) 468-0602
CITY:UKIAHSTATE: CAZIP CODE:
95470
CAPACITY: 4CENSUS: 4DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Keely HansonTIME COMPLETED:
11:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 10:15 AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Caregiver Keely Hanson.
Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Facility Posters are in place at the entrance and throughout the building. Staff conduct a health screening for visitors and staff before coming into work or visit. Facility has PPE supplies. Medications were centrally stored and secure. Toxins were secure and not accessible. Residents do not wear masks inside the facility but have them available. LPA observed Staff were wearing masks during this visit.

There were no deficiencies found in the areas inspected.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1