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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126801871
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:23:48 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
10/31/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20221031122319
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: 28DATE:
12/01/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sara AndersonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not providing adequate food services to residents.
Staff are not meeting resident's showering needs.
Staff are not providing scheduled activities for residents.
Staff are not providing laundry service to residents.
INVESTIGATION FINDINGS:
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Sara Anderson, reviewed records and interviewed staff. Based on records reviewed and interviews conducted, the facility did not provide adequate food services to residents, see complaint 21-AS-20221018160309. Facility is in the process of hiring additional kitchen staff and equipment to ensure residents receive quality food service. Based on interviews conducted, residents are not consistently receiving showers due to a lack of staff. LPA reviewed documentation that showed some residents refused showers while others were not showered due to time or lack of staff. LPA observed there has only been weekly bingo as an activity for several months. Facility is in the process of hiring a designated activities director. Based on interviews conducted, facility was without housekeeping staff and housekeeping duties were not being completed. 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: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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 5
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
10/31/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20221031122319

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: 28DATE:
12/01/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sara AndersonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not administering resident's medication in a timely manner.
INVESTIGATION FINDINGS:
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Sara Anderson, reviewed records and interviewed staff. Based on interviews conducted and records reviewed, LPA could not determine if medications were administered timely. Medication administration logs show when medications are to be given and the staff marks that the medication was given. When a medication is given on an "as needed" basis, the medication is logged and the results are noted. Interviews conducted did not reveal any specific incidents where medication was given late. There was no documentation to support the allegation.
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: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20221031122319
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: 12/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
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 has posted advertisements for additional personnel. Director to submit weekly updates on hiring process to CCL. Cleared during visit.
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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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Type B
12/23/2022
Section Cited
CCR
87464(f)(4)
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87464 Basic Services:(f) Basic services shall at a minimum include:Personal assistance and care as needed by the resident...those activities of daily living such as dressing, eating, bathing. This requirement is not
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Licensee has posted advertisements for additional personnel. Director to submit weekly updates on hiring process to CCL. Cleared during visit.
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met as evidenced by: Based on records reviewed and interviews conducted, Facility did not provide consistant showers for residents. This poses a potential Health risk to residents in care.
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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: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20221031122319
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: 12/01/2022
NARRATIVE
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Care staff were tasked with housekeeping duties and were not keeping up on resident laundry. Facility has now hired housekeeping staff and rooms are being cleaned regularly. Laundry was not being done consistently, but now with housekeeping staff, laundry is being completed on scheduled days and as needed.

Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are 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 Sara Anderson 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: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20221031122319
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: 12/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited
CCR
87219(e)
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87219 Planned Activities:(e)In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities.
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Facility has hired an Activities Director. POC cleared during visit.
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This requirement is not met as evidenced by: Based on interviews conducted, facility does not have an activities staff. This poses a potential risk to residents in care.
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Type B
12/23/2022
Section Cited
CCR
87307(a)(3)(f)
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87307 Personal Accommodations and Services:(3)...the licensee shall assure provision of:(F) Basic laundry service. This requirement is not met as evidenced by: Based on interviews conducted, Facility did
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Facility has hired housekeeping personnel and laundry is being completed consistantly. POC cleared during visit.
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not provide consistant laundry service to residents in care. This poses a potential Health, Safety or Personal Rights risk to residents in care.
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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: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5