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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125000579
Report Date: 02/04/2022
Date Signed: 02/04/2022 11:22:23 AM

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:TIMBER RIDGE AT EUREKAFACILITY NUMBER:
125000579
ADMINISTRATOR:MEREB, WINIFREDFACILITY TYPE:
740
ADDRESS:2740 TIMBER RIDGE LANETELEPHONE:
(707) 443-3000
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:75CENSUS: 48DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Winifred MerebTIME COMPLETED:
11:40 AM
NARRATIVE
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At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. LPA arrived at the facility and had temperature checked and health questions asked. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Administrator Winnie Mereb and toured the facility. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Toxins are stored and not accessible. There was a supply of cleaners, hygiene products and paper products available for resident use.
Facility has submitted and received approval for a Covid Mitigation plan. Posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has PPE supplies. LPA observed the medication carts were in the hallway, unlocked, with no staff nearby. The medication technician arrived a short time later and LPA instructed them to ensure medications are secure when staff are not present. Residents do not typically wear masks inside the facility but have them available. Residents do however, wear masks while away from the facility. All staff had masks on during this visit.

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 Administrator. Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: TIMBER RIDGE AT EUREKA
FACILITY NUMBER: 125000579
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 Medication carts. Both carts were unlocked with no staff present. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2022
Plan of Correction
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Licensee purchased a new medication cart that is self locking. Cleard at time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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