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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126801871
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:46:53 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
09/30/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20220930122431
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: DATE:
11/15/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Dale WoytekTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility is in disrepair.
Facility is unsanitary.
Food services are inadequate.
INVESTIGATION FINDINGS:
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings to an investigation into the above allegations. LPA met with Executive Director Dale Woytek, toured the facility, reviewed records and intereviewed staff and residents. LPA toured the kitchen and inspected equipment. The stove/oven/griddle combination was not in good repair. LPA was informed and observed a crack in the grease tray section of the griddle that has already caused several fires. The last fire caused the grease tray to melt and now it is not removeable. Two of Three ovens are non operational. Facility does not have an area to keep food warm while serving residents, resulting in cold to partially warm food being served to residents. LPA inspected the warming station and found large, rusted holes in the base where water would be. The ventilation unit above the stove was in need of degreasing and cleaning. Unit was not being used during this visit. Two of three freezers in the kitchen are non operational. 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: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
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 4
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
09/30/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20220930122431

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:
11/15/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Dale WoytekTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not ensure that resident's toileting needs were met while in care.
INVESTIGATION FINDINGS:
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings to an investigation into the above allegations. LPA met with Executive Director Dale Woytek, toured the facility, reviewed records and intereviewed staff and residents. Based on interviews conducted and a review of records, LPA could not obtain evidence to support this allegation. LPA learned of a few situations where a resident needed a wheel chair cleaned or a bed changed, due to an accident, but the chair and bed were cleaned in a timely manner and resident was assisted as needed.

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: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
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 4
Control Number 21-AS-20220930122431
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: 11/15/2022
NARRATIVE
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Based on interviews conducted, due to the issues with the warming station and the reduction of useable ovens, food takes longer to be served, which results in cold food being served to residents. Based on interviews conducted and a review of staffing schedules, there is no enough dietary staff to support the kitchen. Caregivers are setting up tables for meals and clearing the dishes afterwards. Caregivers are serving meals. During weekends, staff preparing meals are not trained in food service.

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 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: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20220930122431
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: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
87555(b)(29)
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87555 General Food Service Requirements:(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This
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Licensee will get estimates for each piece of equipment and create a plan for procurement. First estimate has been received. POC cleared during visit.
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requirement is not met as evidenced by: Based on observation Facilities kitchen equipment is not in good repair. This poses a potential Health and Safety risk to residents.
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Type B
12/16/2022
Section Cited
CCR
87555(b)(18)
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87555 General Food Service Requirements:(18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement is not
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Licensee will post advertisements for additional personnel. Director to submit weekly updates on hiring process to CCL.
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met as evidenced by: Based on interviews conducted, Facility does not have trained food service personnel to assist with preparing and serving meals. This poses a potential Health risk to residents.
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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: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4