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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804031
Report Date: 06/10/2024
Date Signed: 06/10/2024 10:28:52 AM

Document Has Been Signed on 06/10/2024 10:28 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: 7DATE:
06/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Kristin BognerTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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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 (2) SOC 341, Report of suspected dependent adult/elder abuse forms received by the Department. LPA met with PQI Director Kristin Bogner, interviewed staff and reviewed records. Based on a review of records and interviews conducted, a report was made that a facility staff was violating the personal rights of two clients. The facility conducted an internal investigation in regards to the allegations. The investigation found staff was following facility protocols by conducting observations and 15 minute bed checks. The staff was relocated from the facility while the investigation was being conducted. The results of the investigation were found to be unsubstantiated.

No citations issued during this visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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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