216804183-1-30-2025-21-AS-SHAN-DDETL3-20250130134852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804183
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:03:22 PM

Document Has Been Signed on 01/30/2025 03:03 PM - 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:	MEADOW CREEK SENIOR LIVING		FACILITY NUMBER:	216804183
ADMINISTRATOR/ DIRECTOR:	MUELRATH, KELLY		FACILITY TYPE:	740
ADDRESS:	40 MEADOW WAY		TELEPHONE:	(707) 799-1557
CITY:	SAN GERONIMO	STATE: CA	ZIP CODE:	94963
CAPACITY: 6		CENSUS: 6	DATE:	01/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Licensee, Kelly Muelrath		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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

Licensing Program Analyst (LPA) Shannan Hansen arrived to conduct an annual unannounced inspection of this licensed senior care facility at approximately 8:45AM. LPA met with Licensee/Administrator Kelly Muelrath. The facility is a single story 3 bedroom, 2 bathrooms with currently 6 residents of which 3 have diagnoses of dementia and 2 are receiving hospice care. Facility has been cleared for hospice waiver of 2.

At approximately 8:45AM LPA toured the building and grounds with Licensee/Administrator which were found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity space & activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezers were clean, and food was stored properly. Toxins are stored in locked closet across from laundry room & in locked cabinets under kitchen-sink. Water temperature measured 107.9 degrees F & 117.3 degrees F, within regulations of 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers were last charged 1/8/2025. There are 7 hardwired combination smoke /carbine monoxide detectors last inspected 1/8/2025 along with 2 additional carbon monoxide detectors found to be operational. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

At approximately 9:30 AM, LPA reviewed 5 resident records and found all residents have current physician's reports & care plans. All resident records contained current and signed admission agreements and contained physician's medication orders for each resident.

At approximately 11:20 AM, LPA reviewed 6 staff records. All records contained documentation of completed training as required. Evidence of current first aid and CPR training were present.

At approximately 11:00 AM the Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 1/30/2025 at 11:05 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.
Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MEADOW CREEK SENIOR LIVING	FACILITY NUMBER: 216804183
	VISIT DATE: 01/30/2025

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
26
27
28
29
30
31
32

Continued from LIC908

At approximately 12:50PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility does not handle resident cash.

Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts and documents disaster drills monthly & in different shifts with the last being 1/1/2025. Administrator Certificate’s for Kelly Muelrath # 6067128740 Exp. 9/26/2025.

Facility activities include weekly musical performances, yoga instructor for “chair yoga”, and art therapist as well as options of nightly games. While conducting annual inspection LPA observed ukulele player performing sing a longs with residents and staff who were all engaged. The back porch of the house is shaded and provides a safe and secure area for residents to spend time outside.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 2/14/2025:

LIC 308 Designated (if changes)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changed)
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3