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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 121372020
Report Date: 08/20/2024
Date Signed: 08/20/2024 12:15:15 PM


Document Has Been Signed on 08/20/2024 12:15 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:FRYE'S CARE HOMEFACILITY NUMBER:
121372020
ADMINISTRATOR:DELORES FRYEFACILITY TYPE:
740
ADDRESS:2240 FERN STREETTELEPHONE:
(707) 442-2712
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:58CENSUS: 34DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Katelyn FormbyTIME COMPLETED:
12:30 PM
NARRATIVE
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management in regards to an incident report submitted to the department on 08/12/2024. LPA met with Manager Katelyn Formby and reviewed records. On 08/10/2024, Resident, R1, received another residents medication. During an evening medication pass, staff gave R1 the wrong cup of medications. After R1 had already taken the pills, staff noticed it was the incorrect medication. Physician was notified and informed staff to observe resident for changes. Approximately 6 hours later, staff observed R1 to have lower than normal blood pressure and contacted emergency personnel. Resident stayed in the hospital for observation. LPA reviewed discharge paperwork and observed resident had no long term effects from the medication error. Staff was retrained on facility medication practices.

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 Katelyn Formby and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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Document Has Been Signed on 08/20/2024 12:15 PM - It Cannot Be Edited

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: FRYE'S CARE HOME
FACILITY NUMBER: 121372020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed
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Facility conducted retraining for responsible staff. POC cleared at time of visit.
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Licensee did not ensure R1 received the correct medication. This poses an immediate Health risk to residents in care.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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