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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126801871
Report Date: 06/28/2023
Date Signed: 06/28/2023 09:59:41 AM


Document Has Been Signed on 06/28/2023 09:59 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:ALDER BAY ASSISTED LIVINGFACILITY NUMBER:
126801871
ADMINISTRATOR:ANDERSON, SARAFACILITY TYPE:
740
ADDRESS:1355 MYRTLETELEPHONE:
(707) 444-8000
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:49CENSUS: 27DATE:
06/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Sara AndersonTIME COMPLETED:
10:15 AM
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an incident report submitted to CCL on 06/16/2023. The incident was in regards to a resident falling in their room and going to the emergency room. The incident report did not explain the extent of the residents injuries. LPA met with Executive Director Sara Anderson and reviewed records. R1 activated their pendant alarm to request assistance. Staff found R1 on the floor of their bathroom and R1 was not able to recall how the incident occurred. Staff contacted emergency personnel and R1 was transported to the hospital. Resident returned the same day with no injury.

LPA discussed with Executive Director the policies and procedures of reporting incidents to families.

LPA received copies of documents.

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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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