125000579-12-24-2021-21-AS-CMAZ-C9ZMWD-20211224085810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 125000579
Report Date: 10/27/2021
Date Signed: 12/24/2021 08:40:27 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
10/25/2021 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20211025162155

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:	DATE:	10/27/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Larona Farnum and Winnie Mereb		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not seek timely medical for resident in care

INVESTIGATION FINDINGS:

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**Amended** LPA amended 9099 to correct the allegation above. Nothing was changed in the body of this document. Signature scanned over from licensee for change. At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived to this facility unannounced, to conduct an investigation into the above allegation. LPA met with Administrator Winne Mereb and Licensee Larona Farnum, interviewed staff, toured the facility and reviewed records. The incident was in regards to a resident being found on the floor of their bathroom, unresponsive. Facility contacted emergency personnel immediately and Hospice was notified. Resident was pronounced deceased at the facility. LPA reviewed resident call log history. Response times ranged from under 1 minute to 8 minutes. Facility followed regulation and notified all responible parties as required by regulation.
This agency has investigated the above allegation. 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.

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: 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.

LIC9099 (FAS) - (06/04)

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