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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126801871
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:07:22 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
10/04/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20221004173642
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:
10/06/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dale WoytekTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff not fingerprint cleared and/or associated.
INVESTIGATION FINDINGS:
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At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegation. LPA met with Administrator Daly Woytek, toured the facility, reviewed records and interviewed staff and residents. LPA reviewed staff schedules and compaired them to the background clearance records for the facility. Based on this record review, LPA observed S1 and S2, currently working at the facility, did not have a background clearance. LPA observed S3 and S4, no longer employed at the facility, had worked at the facility without a background clearance. A civil penalty is being issued in the amount of $2000.
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.
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: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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
Control Number 21-AS-20221004173642
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: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2022
Section Cited
CCR
87355(e)(1)
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87355 Criminal Record Clearance:(e)(1)Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: Based on record
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Licensee understands all staff need to receive a background clearance prior to working at the facility. Licensee will ensure S1 and S2 receive background clearance prior to working. S3 and S4 no longer
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review and interviews conducted, S1, S2, S3 and S4 did not have a fingerprint clearance prior to working at facility. A civil penalty of $2000 is being issued.
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work at facility. Licensee to submit documentation that S1 and S2 have received background clearance or exemption, or approval to work during process. S1 and S2 were removed from facility at time of visit. POC cleared.
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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: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
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