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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803625
Report Date: 11/01/2022
Date Signed: 11/01/2022 10:37:22 AM

Document Has Been Signed on 11/01/2022 10:37 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:
11/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brandon HireTIME COMPLETED:
10:45 AM
NARRATIVE
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an unusual incident report submitted to CCL on 10/31/2022. LPA met with Administrator Brandon Hire and reviewed records. The incident was in regards to a medication error. Staff did not assist with a clients morning medication on 10/28/2022. Administrator Brandon Hire scheduled retraining for S1 and training was conducted 11/01/2022. Facility contacted all relevant parties per regulation.

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 Brandon Hire and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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Document Has Been Signed on 11/01/2022 10:37 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 11/01/2022 at 09:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MENDO HOUSE
FACILITY NUMBER: 236803625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited
CCR
80075(b)

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80075 Health Related Services:(b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on
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Licensee to ensure clients are assisted with medication as needed and medications are given as ordered. Licensee scheduled training which was conducted on 11/01/2022.
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records reviewed, Licensee did not ensure clients were assisted with medications as required. This poses an Immediate Health, Safety or Personal Rights risk to clients in care.
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Signed certification of completed training was received during visit. POC Cleared during visit.

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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
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022


LIC809 (FAS) - (06/04)
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