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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125000579
Report Date: 09/23/2022
Date Signed: 09/23/2022 09:37:27 AM


Document Has Been Signed on 09/23/2022 09:37 AM - 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:FARNUM, LARONAFACILITY TYPE:
740
ADDRESS:2740 TIMBER RIDGE LANETELEPHONE:
(707) 443-3000
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:75CENSUS: 57DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Larona FarnumTIME COMPLETED:
09:45 AM
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a death report submitted by the facility on 09/21/2022. LPA met with Administrator Larona Farnum and reviewed records. Facility staff observed the resident was having breathing issues and contacted emergency medical personnel. Resident was transported to the hospital via an ambulance. Based on a record review, there were no special precautions or indications of the breathing issue. Resident was admitted to the hospital and later passed away. Resident family notified the facility.
Based on records reviewed, facility provided the needed services of the resident and ensured resident received medical attention in a timely manner.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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