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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125000579
Report Date: 03/02/2022
Date Signed: 03/02/2022 04:25:56 PM


Document Has Been Signed on 03/02/2022 04:25 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: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: DATE:
03/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Larona FarnumTIME COMPLETED:
04:45 PM
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At approximately 3:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an incident report submitted to CCL 01/07/2022. LPA met with Licensee Larona Farnum. R1 was found in their room, slumped over in the bed. Staff came to the room to assist resident getting ready for lunch and found R1 unresponsive and immediately called emergency personnel. Emergency personnel arrived and pronounced R1 deceased. An investigation is being conducted by the Humboldt County Sheriff's department. The findings of the investigation will be forwarded to CCL when facility receives them.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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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