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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001177
Report Date: 11/08/2022
Date Signed: 11/08/2022 10:38:14 AM

Document Has Been Signed on 11/08/2022 10:38 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:HCAR BAY CENTERFACILITY NUMBER:
125001177
ADMINISTRATOR:JANTZ, ROSSFACILITY TYPE:
775
ADDRESS:1001 SEARLESS STREETTELEPHONE:
(707) 441-8625
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 75CENSUS: 25DATE:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Wes PattersonTIME COMPLETED:
10:45 AM
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At approximately 9:50AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to a choking incident that occurred on 11/03/2022. LPA met with Program Director Wes Patterson and reviewed records. Based on a review of records, there were no special diet restrictions and no previous swallowing issues with client, C1. C1 was sitting and eating lunch when all of a sudden, C1 ran towards the restroom. Staff were following when C1 collapsed in the doorway to the restroom. Staff began CPR and alerted emergency services. C1 was taken to the hospital and admitted. Facility made the appropriate notifications. No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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