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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126801871
Report Date: 09/16/2022
Date Signed: 09/16/2022 12:50:43 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
08/05/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20220805163150
FACILITY NAME:ALDER BAY ASSISTED LIVINGFACILITY NUMBER:
126801871
ADMINISTRATOR:IVORY, JOH-NIKAFACILITY TYPE:
740
ADDRESS:1355 MYRTLETELEPHONE:
(707) 444-8000
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:49CENSUS: 32DATE:
09/16/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dale WoytekTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not being properly trained
Facility is in disrepair
INVESTIGATION FINDINGS:
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility, unannounced, to complete an investigation into the above allegations. LPA met with Executive Director Dale Woytek, toured the building, interviewed staff and reviewed records. During the course of this investigation, LPA reviewed staff training records and interviewed staff regarding the training they received. LPA was informed that the training consisted mostly of watching a video and shadowing another staff, then they would work on their own after approximately 2-3 days. LPA was provided documentation of staff training hours for 10 staff. Of the 10 staff, only 1 out of 10 had the required annual 20 hours of training. LPA toured the facility on 08/04, 08/11 and 8/24/2022. LPA observed carpets in need of cleaning and a door in the hallway that was broken. LPA was informed by Dale that new doors are in the process of being ordered. It is a challenge in this area due to the lack of availability so they are ordering from another region. 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: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
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
08/05/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20220805163150

FACILITY NAME:ALDER BAY ASSISTED LIVINGFACILITY NUMBER:
126801871
ADMINISTRATOR:IVORY, JOH-NIKAFACILITY TYPE:
740
ADDRESS:1355 MYRTLETELEPHONE:
(707) 444-8000
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:49CENSUS: DATE:
09/16/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dale WoytekTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff is providing care and supervision while being ill
Staff do not meet the minimum qualifications required
Staff are intoxicated while on the facility grounds
Staff are not meeting the residents diabetic needs
Residents rooms are not being properly maintained
Staff are not providing appropriate care and supervision to the residents
Staff do not have access to gloves while in care
INVESTIGATION FINDINGS:
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility, unannounced, to complete an investigation into the above allegations. LPA met with Executive Director Dale Woytek, toured the building, interviewed staff and reviewed records. Based on interviews conducted, a staff memeber became ill while cleaning the kitchen area. Staff member was not providing care to residents and secluded themselves in an office. LPA reviewed staff records and found care staff, though lacking in training, met all other minimum qualifications. LPA addressed Administrator qualifications in a previous complaint (21-AS-20220802120803) and the issue was resolved. LPA interviewed staff and there was no supporting evidence to show a staff was on facility grounds while intoxicated. LPA reviewed resident records and found diabetic residents are able to manage their administration of medications. LPA spoke with Director to ensure sharps containers are within easy reach to discard used equipment. Continued on LIC9099-C...
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: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
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 5
Control Number 21-AS-20220805163150
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: 09/16/2022
NARRATIVE
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LPA toured the facility during the course of this investigation and found some of the carpets in resident rooms were in need of cleaning, and learned facility has a procedure to ensure the carpets are cleaned. Director will schedule with an outside company to conduct the quarterly cleaning. Based on interviews conducted and a review of resident records, LPA did not find evidence to show residents have not received appropriate care and supervision. Based on interviews conducted, there was one weekend where staff were running low on gloves and could not access the supply, due to them being locked in the Directors office. There were gloves available to make it through the weekend, and the storage of gloves has been relocated to ensure this event does not occur again.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220805163150
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: 09/16/2022
NARRATIVE
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The carpets are cleaned using a small carpet cleaner and facility will schedule an outside company to conduct a deep clean.

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 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: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220805163150
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: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
87412(c)
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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 a
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Executive Director has evaluated the training program and made changes to ensure staff receive training and it is documented correctly. POC cleared at time of visit.
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Record review, Licensee did not ensure documentation of staff receiving the required training and orientation. This poses a potential Health, Safety or Personal rights risk to residents.
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Type B
10/14/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on visual observation, LPA observed a door
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Licensee is working on ordering a new door. Due to lack of availablility in this region, Director is searching outside the area for a new door. Director will submit documentation to LPA that a new door has been
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in the first floor hallway to be broken. This poses a potential Safety risk for residents in care.
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purchased. Copy of invoice to be submitted to LPA by POC date of 10/14/2022.
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: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5