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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804183
Report Date: 11/20/2025
Date Signed: 11/20/2025 03:08:11 PM

Document Has Been Signed on 11/20/2025 03:08 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 LIVINGFACILITY NUMBER:
216804183
ADMINISTRATOR/
DIRECTOR:		MUELRATH, KELLYFACILITY TYPE:
740
ADDRESS:40 MEADOW WAYTELEPHONE:
(707) 799-1557
CITY:SAN GERONIMOSTATE: CAZIP CODE:
94963
CAPACITY: 6CENSUS: 6DATE:
11/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Kelly Muelrath, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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At approximately 8:45 AM Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an annual inspection of this licensed senior care facility. LPA met with Licensee/Administrator Kelly Muelrath. The facility is single story, with 3 bedrooms and 2 bathrooms. Facility has a fire clearance for 6 non-ambulatory residents and Hospice waiver for 3. There are currently 6 residents in care, of which 3 have diagnoses of dementia and 2 are receiving hospice.

At approximately 8:55 AM LPA toured the building and grounds with Licensee/Administrator which were found to be at a comfortable temperature, 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 between 107.6 degrees F & 107.9 degrees F, within regulations of 105 degrees F and 120 degrees F at faucets accessible to residents. Bathrooms were equipped with necessary grab bars, and slip-resistant mats and shower chairs in both shower floors as required by Title 22 regulations. Fire extinguishers were last charged 1/8/2025. There are 7 hardwired combination smoke /carbine monoxide detectors last inspected 10/7/2025 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 9:45 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, as well as all required documentation. Continue on LIC809

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/20/2025
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Continued from LIC809

At approximately 11:35 AM, LPA reviewed 5 staff records. All records contained documentation of completed training as required. Evidence of current first aid and CPR training were present. All staff records reviewed had required criminal record clearance and associated.

At approximately 12:20 PM the Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 11/20/2025. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

At approximately 12:50PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an emergency outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations.

Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts and documents disaster drills quarterly & in different shifts with the last being 10/7/2025. Administrator Certificate’s for Kelly Muelrath # 7031393740 Exp. 9/26/2027.

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 12/15/2025:
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 (when receive)
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
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