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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125000579
Report Date: 10/27/2021
Date Signed: 10/27/2021 12:32:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 EUREKAFACILITY NUMBER:
125000579
ADMINISTRATOR:FARNUM, ERICAFACILITY TYPE:
740
ADDRESS:2740 TIMBER RIDGE LANETELEPHONE:
(707) 443-3000
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:75CENSUS: DATE:
10/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Larona FarnumTIME COMPLETED:
11:02 AM
NARRATIVE
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived to this facility for a complaint investigation. During this investigation, LPA reviewed records and found facility failed to submit a written death report for R1 on 09/29/2021. LPA was notified by telephone of the incident and all responsible parties were notified. A written incident report was created but not sent. LPA received completed Special incident report and death report during this visit. LPA requested training be conducted for staff responsible for reporting.

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 Licensee 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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited

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Death of any resident from any cause regardless of where the death occurred, ...a hospital, or visiting away from the facility. This requirement is not met as evidenced by: Based on record
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review, Licensee did not submit a written report for a death that occurred on 09/29/2021. This poses a potential health, safety or personal rights risk to residents.
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to CCL by POC date of 11/19/2021.

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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: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021
LIC809 (FAS) - (06/04)
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