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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126801871
Report Date: 03/04/2025
Date Signed: 03/04/2025 12:30:34 PM

Document Has Been Signed on 03/04/2025 12:30 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:ALDER BAY ASSISTED LIVINGFACILITY NUMBER:
126801871
ADMINISTRATOR/
DIRECTOR:		ANDERSON, SARAFACILITY TYPE:
740
ADDRESS:1355 MYRTLETELEPHONE:
(707) 444-8000
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 49CENSUS: 22DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Sara AndersonTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Sara Anderson and explained the purpose of the visit. Administrator certificate is current. Facility has a Hospice waiver for 5 residents.

At approximately 9:30AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. Facility kitchen exhaust unit was not operational and is being replaced. Facility has made temporary adjustments to ensure residents meals are not affected. All bedrooms had required furniture, bedding, and lighting. The kitchen contained cooking/dining equipment that was clean and orderly, utensils were present. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature and logs are kept. Facility has required seven-day non-perishable and two-day perishable supply of food. Emergency food stores and water was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. Evacuation chairs were present at each stairwell.

At approximately 10:30AM, LPA conducted a review of medications. Medication is locked and not accessible. First aid kit was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting drills every 3 months.

At approximately 10:50AM, LPA reviewed 5 of 22 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of a physician visit occurring within the last 12 months was present. Hospice care plans were present.

Continued on LIC809-C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/04/2025
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At approximately 11:30AM, LPA reviewed 5 of 23 staff files. Staff files reviewed contained evidence of completed annual training. First Aid/CPR certification was current.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:


Evidence of control of Property, (Current Rental/Lease Agreement/Deed)
LIC500- Personnel Report
LIC309- Administrative Organization

LPA received the following documents during this visit:
Evidence of Liability Insurance
Register of Residents
Updated resident intake forms, Physician Report

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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