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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803625
Report Date: 08/02/2024
Date Signed: 08/02/2024 09:29:24 AM

Document Has Been Signed on 08/02/2024 09:29 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/
DIRECTOR:		HIRE, BRANDONFACILITY TYPE:
735
ADDRESS:1116 WEST PERKINS STREETTELEPHONE:
(707) 468-0602
CITY:UKIAHSTATE: CAZIP CODE:
95470
CAPACITY: 4CENSUS: DATE:
08/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Brandon HireTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
NARRATIVE
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to two reports of medication errors submitted by facility. LPA met with Administrator Brandon Hire and reviewed records. The first occurrence was due to a staff administering medication but did not log that it was given. The oncoming staff saw the medication was not logged and administered the medication again. The second occurrence involved a staff prepping the medication but not administering it. The oncoming shift noticed the medication was still in the locked medication cabinet. Licensee conducted refresher training for the staff on 07/25/2024. Training included proper documentation and reporting requirements.

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: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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Document Has Been Signed on 08/02/2024 09:29 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 08/02/2024 at 08:54 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: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2024
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 conducted refresher medication training on 07/25/2024.
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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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POC cleared at time of 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: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
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