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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804031
Report Date: 07/30/2024
Date Signed: 07/30/2024 10:59:20 AM

Document Has Been Signed on 07/30/2024 10:59 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:PHOENIX HOUSEFACILITY NUMBER:
236804031
ADMINISTRATOR/
DIRECTOR:		ADDISON, DENISEFACILITY TYPE:
772
ADDRESS:641 S ORCHARD AVETELEPHONE:
(707) 467-2010
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 8CENSUS: 6DATE:
07/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Denise AddisonTIME VISIT/
INSPECTION COMPLETED:
11:15 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 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived to this facility unannounced to conduct a case management visit in regards to an unusual incident report submitted by facility on 06/28/2024. LPA met with Administrator Denise Addison and reviewed records. The incident in question was a medication error that occurred on 06/25/2024. Staff was pouring medications while having a conversation and became distracted. Staff gave a medication that was supposed to be given in the mornings instead of the medication that was for the evenings. The error was discovered during the night time change of shift. Facility conducted refresher training for staff responsible.

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 Administrator and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 2
Document Has Been Signed on 07/30/2024 10:59 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 07/30/2024 at 10:04 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: PHOENIX HOUSE
FACILITY NUMBER: 236804031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2024
Section Cited
CCR
81075(b)

1
2
3
4
5
6
7
81075 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
1
2
3
4
5
6
7
Licensee to ensure clients receive medication as ordered by Physician. Staff has been assigned refresher medication training. Licensee shall submit proof of completed training to CCL by POC date of 07/31/2024.
8
9
10
11
12
13
14
records reviewed, Licensee did not ensure medications were given per physician orders. C1 was given the wrong medication, which poses an immediate Health or Safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2