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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 121372020
Report Date: 12/02/2022
Date Signed: 12/02/2022 09:25:36 AM


Document Has Been Signed on 12/02/2022 09:25 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:FRYE'S CARE HOMEFACILITY NUMBER:
121372020
ADMINISTRATOR:FRYE, PYONG SILFACILITY TYPE:
740
ADDRESS:2240 FERN STREETTELEPHONE:
(707) 442-2712
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:58CENSUS: 22DATE:
12/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dee Dee FryeTIME COMPLETED:
09:45 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 a death report submitted to CCL on 11/21/2022. LPA met with Administrator Dee Dee Frye and reviewed records. The death report stated R1 was found in their room unresponsive. R1 was not receiving Hospice services. Upon discovering R1, staff immediately contacted emergency personnel. Emergency personnel pronounced resident deceased at facility. Facility will send a copy of the death certificate to CCL when they receive. Facility followed regulation.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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