125000579-5-17-2021-21-AS-BMOS-C35REV-20210518125811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 125000579
Report Date: 04/16/2021
Date Signed: 05/17/2021 09:33:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2021 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210225145335

FACILITY NAME:	TIMBER RIDGE AT EUREKA		FACILITY NUMBER:	125000579
ADMINISTRATOR:	FARNUM, ERICA		FACILITY TYPE:	740
ADDRESS:	2740 TIMBER RIDGE LANE		TELEPHONE:	(707) 443-3000
CITY:	EUREKA	STATE: CA	ZIP CODE:	95503
CAPACITY:	75	CENSUS: 50	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Larona Farnum		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility neglect resulted in resident's death
Facility staff did not assist resident with eating and/or drinking
Facility staff did not meet resident's hygiene needs
Facility staff did not keep the facility clean
Facility staff did not dispense medication as prescribed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***Report was amended virtually*** At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived to this facility unannounced to deliver findings for the allegations listed above. LPA met with Executive Director Larona Farnum. Based on interviews conducted and a review of records, the facility followed regulation and their plan of operation in the care of residents at the facility. Facility documents when there is a change in condition for residents and submits incident reports as required by regulation. The care needs of residents that require assistance with eating or drinking are addressed in the care plan. The assistance is provided on a 1 to 1 basis and as needed per the care plan and facility procedures. Hygiene needs are also addressed in the care plan and provided. Residents receive assistance with bathing and dressing as needed. The facility documents when showers are provided or declined. At approximately 11:00AM, LPA toured the building and found it to be clean and in good repair. Hallways and exit doors are unobstructed. Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2021 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210225145335

FACILITY NAME:	TIMBER RIDGE AT EUREKA		FACILITY NUMBER:	125000579
ADMINISTRATOR:	FARNUM, ERICA		FACILITY TYPE:	740
ADDRESS:	2740 TIMBER RIDGE LANE		TELEPHONE:	(707) 443-3000
CITY:	EUREKA	STATE: CA	ZIP CODE:	95503
CAPACITY:	75	CENSUS: 50	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Larona Farnum		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not schedule nurse visits for the resident

Facility staff did not address flies in the facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***Report was amended virtually*** At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived to this facility unannounced to deliver findings for the allegations listed above. LPA met with Executive Director Larona Farnum. LPA reviewed documents regarding home health visits. The visits are scheduled by the home health agency and not the facility. The facility is responsible to observe residents for changes in condition and to notify the physician or emergency personnel. Facility alerted the physycian and emergency personnel when resident was observed to have a change in condition. LPA toured the facility and observed commercial fly traps located throughout the facility. The kitchen is equiped with fly guards and traps near the doors. Facility also utilizes a smaller fly trap near the fresh juice machine. Based on interviews conducted, a physical tour of the facility and a review of documents the allegations are Unfounded.
.... Continued on LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20210225145335

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: TIMBER RIDGE AT EUREKA	FACILITY NUMBER: 125000579
	VISIT DATE: 04/16/2021

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	This agency has investigated the above allegations. We have found that the complaint was unfounded meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No citations issued. Original Signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20210225145335

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: TIMBER RIDGE AT EUREKA	FACILITY NUMBER: 125000579
	VISIT DATE: 04/16/2021

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

Based on interviews conducted and a review of records, facility staff followed physician orders in the administration of medication. The facility sought physician guidance regarding an upcoming surgery and followed the orders to hold medication 2 days prior to the procedure and to restart when needed. LPA received the physicians order to hold medication. Larona told LPA that she was informed by family to hold medication again on 10/4/2019. She said that she contacted physician to verify the hold and was given verbal confirmation and a written order was to be sent to facility. Due to the amount of time since this incident, facility staff could not recall why the written order did not arrive or why facility did not follow up.

The allegations were based on incidents that are alleged to occur in 2019. The resident file was stored in line with regulation. Staff were not able to remember details relating to that time period with clarity.

Based on interviews conducted and a review of documents the allegations are Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

No citations issued.

Original signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4