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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001177
Report Date: 08/28/2023
Date Signed: 08/28/2023 12:33:11 PM

Document Has Been Signed on 08/28/2023 12:33 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:HCAR BAY CENTERFACILITY NUMBER:
125001177
ADMINISTRATOR:KIM NASHFACILITY TYPE:
775
ADDRESS:1001 SEARLESS STREETTELEPHONE:
(707) 441-8625
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 75CENSUS: 25DATE:
08/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Wes PattersonTIME COMPLETED:
12:45 PM
NARRATIVE
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At approximately 11:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to a medication error that occurred on 06/15/2023. LPA met with Program Director Wes Patterson. Based on interviews conducted, the error occurred due to a staff forgetting to assist the resident at the proper time. Facility has updated their medication procedures and set up reminders on multiple devices to ensure client receives their medication at the proper time.

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 Wes Patterson and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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Document Has Been Signed on 08/28/2023 12:33 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 08/28/2023 at 12:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HCAR BAY CENTER
FACILITY NUMBER: 125001177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2023
Section Cited
CCR
82075

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82075 Health-Related Services:(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on file
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Licensee to ensure clients receive assistance with medications. Procedures were updated and reminders were set up on mulitiple devices to ensure client receives their medication at the proper time.
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review, Facility staff did not assist client as needed with daily medication. This poses an immediate Health risk to clients in care.
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POC cleared at time of visit.

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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 Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
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