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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803939
Report Date: 01/04/2021
Date Signed: 01/04/2021 04:13:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ESPECIALLY YOU ASSISTED LIVING, INC.FACILITY NUMBER:
126803939
ADMINISTRATOR:MITCHELL, AMANDA L.FACILITY TYPE:
740
ADDRESS:12 HENDERSON STREETTELEPHONE:
(707) 443-8838
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:15CENSUS: 9DATE:
01/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Loren NeufeldTIME COMPLETED:
03:15 PM
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At approximately 1:00PM, Licensing Program Analyst (LPA) Chris Arnhold contacted Applicant Loren Neufeld and Administrator Amanda Mitchell to conduct a pre-licensing facility inspection. This inspection is being conducted by video due to COVID-19 precautions.

LPA toured the home with the Administrator and Applicant. The home is a 9 bedroom home with a dining room and living room. There is a staff breakroom upstairs. There is a sunroom at the rear of the house where activities are conducted. The hot water was checked at 119 F in the kitchen. All fire extinguishers were fully charged. All fire exits were unobstructed. Facility smoke detectors are operational. There was a sufficient supply of perishable and nonperishable food. Medications are centrally stored and locked in a medication cart in the staff office. Staff and Resident files are stored in the staff office. There was a sufficient supply of linens, dishes, silverware and furnishings. Toxins are locked and inaccessible.

LPA conducted Component 3 orientation with Administrator and Applicant.

Based on this inspection, facility is in compliance with regulation. License will be issued upon completion of a final file review.

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

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
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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