126801871-12-20-2022-21-AS-BMOS-CNLP5F-20230131100037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126801871
Report Date: 12/20/2022
Date Signed: 12/20/2022 02:17:10 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
11/22/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20221122121315

FACILITY NAME:	ALDER BAY ASSISTED LIVING		FACILITY NUMBER:	126801871
ADMINISTRATOR:	DALE WOYTEK		FACILITY TYPE:	740
ADDRESS:	1355 MYRTLE		TELEPHONE:	(707) 444-8000
CITY:	EUREKA	STATE: CA	ZIP CODE:	95501
CAPACITY:	49	CENSUS:	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Sara Anderson		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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9

Facility staff are not properly trained.

INVESTIGATION FINDINGS:

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At approximately 11:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Sara Anderson, reviewed records and interviewed staff. LPA reviewed staff training records and found a lack of required annual training. Executive Director has implemented a training plan to ensure staff receive the required hours of training.
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 Executive Director and Appeal rights were given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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 3

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
11/22/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20221122121315

FACILITY NAME:	ALDER BAY ASSISTED LIVING		FACILITY NUMBER:	126801871
ADMINISTRATOR:	DALE WOYTEK		FACILITY TYPE:	740
ADDRESS:	1355 MYRTLE		TELEPHONE:	(707) 444-8000
CITY:	EUREKA	STATE: CA	ZIP CODE:	95501
CAPACITY:	49	CENSUS:	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Sara Anderson		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff mismanges resident's medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 11:45AM, 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. LPA reviewed medication records in regards to medication ordering and administration. There was no supporting evidence to show that a residents medication was not managed appropriately. LPA interviewed medication technician and was informed of the process on how medications are ordered and delivered. There was no way to verify if a medication was delivered unless it was logged into the centrally stored record. There were no notations showing missing medications.
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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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 3

Control Number 21-AS-20221122121315

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: 12/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/30/2022 Section Cited CCR 87412(c)	1 2 3 4 5 6 7	87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on	1 2 3 4 5 6 7	Executive Director has created a training plan to ensure staff receive required training. POC Cleared at time of visit.
	8 9 10 11 12 13 14	record review, facility staff did not have sufficient documented annual training hours. This poses a potential Health, Safety or personal rights risk to residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3