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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126801871
Report Date: 11/15/2022
Date Signed: 11/15/2022 05:22:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20221018160309
FACILITY NAME:ALDER BAY ASSISTED LIVINGFACILITY NUMBER:
126801871
ADMINISTRATOR:DALE WOYTEKFACILITY TYPE:
740
ADDRESS:1355 MYRTLETELEPHONE:
(707) 444-8000
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:49CENSUS: DATE:
11/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dale WoytekTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility failed to meet residents care needs
Facility not providing adequate meal service
INVESTIGATION FINDINGS:
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings to an investigation into the above allegations. LPA met with Executive Director Dale Woytek, toured the facility, reviewed records and intereviewed staff and residents. Based on interviews conducted and LPA observation, care staff did not meet the needs of residents on at least two occasions. During a visit on 11/07/2022, LPA witnessed staff not provide shower assistance due to not having enough staff on duty at the time. LPA inquired if this situation occurred often and was told that it was not a daily issue, but did happen often. LPA observed meal service on several occasions during this investigation. LPA observed the meal during the morning and afternoon was served in a timely manner. During the evening meals, LPA was informed that food served to residents is luke warm or cold, due to the lack of a warming station and lack of space in the kitchen to prep the plates of food for residents. Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20221018160309

FACILITY NAME:ALDER BAY ASSISTED LIVINGFACILITY NUMBER:
126801871
ADMINISTRATOR:DALE WOYTEKFACILITY TYPE:
740
ADDRESS:1355 MYRTLETELEPHONE:
(707) 444-8000
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:49CENSUS: DATE:
11/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dale WoytekTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Kitchen staff rude to residents
Dining room tables are not kept sanitary
INVESTIGATION FINDINGS:
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings to an investigation into the above allegations. LPA met with Executive Director Dale Woytek, toured the facility, reviewed records and intereviewed staff and residents. Based on interviews conducted, LPA was not able to find evidence where a kitchen staff was rude to residents. LPA observed meal service during several visits, seeing all three meals being served and cleaned up. Due to a lack of dining aides, tables were not cleaned as dishes were being picked up, however dining tables were cleaned and sanitized when the rest of the items were cleaned. LPA inspected each table and did not see any chips or broken edges that would not allow the table to be properly sanitized.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20221018160309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ALDER BAY ASSISTED LIVING
FACILITY NUMBER: 126801871
VISIT DATE: 11/15/2022
NARRATIVE
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LPA was not able to verify past meals as there were a lack of "As served" menus on record. LPA was informed that menu's are not accurate because of a lack of supplies to make the food listed.

Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

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

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20221018160309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ALDER BAY ASSISTED LIVING
FACILITY NUMBER: 126801871
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is
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Licensee will post advertisements for additional personnel. Director to submit weekly updates on hiring process to CCL.
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not met as evidenced by: Based on interviews conducted, Facility did not have enough staff to ensure residents needs were met. This poses a potential Health, Safety or Personal right risk to residents.
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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: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4