126803939-12-14-2021-21-AS-CMAZ-C9Z2HV-20211223162521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803939
Report Date: 12/14/2021
Date Signed: 12/14/2021 03:32:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2021 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20211108144904

FACILITY NAME:	ESPECIALLY YOU ASSISTED LIVING, INC.		FACILITY NUMBER:	126803939
ADMINISTRATOR:	MITCHELL, AMANDA L.		FACILITY TYPE:	740
ADDRESS:	12 HENDERSON STREET		TELEPHONE:	(707) 443-8838
CITY:	EUREKA	STATE: CA	ZIP CODE:	95501
CAPACITY:	15	CENSUS: 11	DATE:	12/14/2021
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Amanda Mitchell		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Neglect/ lack of supervision

INVESTIGATION FINDINGS:

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At approximately 2:45PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver investigation findings for the above allegation. LPA met with Administrator Amanda Mitchell. This incident occurred while this facility was under different ownership, License# 126801773. The change of ownership occurred on 01/19/2021. The results of this investigation are as follows: Based on a record review and interviews conducted, the facility observed swelling on the leg of R1 on 09/23/2020. Based on interviews conducted with Administrator, R1 did not complain of pain at this time. Facility staff contacted R1's Registered Nurse (RN) from PACE and she came to facility to evaluate. The RN ordered an X-ray, which was performed 09/25/2020, which showed a fracture. There were no reported falls in the weeks prior to the incident and staff stated they would have known if a fall occurred, due to R1 not being able to get up after a fall. A review of resident records, indicated resident was diagnosed with several ailments that caused weak skeletal structure. Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20211108144904

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 12/14/2021

NARRATIVE

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Records reviewed show an overall decline in health of R1 and a referral for Hospice care was generated on 09/30/2020. A review of the Hospice intake documents, notes the fractures and attributes to a recent fall. However, there is no documented evidence or interview that supports this note. A review of the Hospice care plan shows R1 had limited mobility and was bed bound and had chronic dementia without behavioral disturbance. The plan notes R1 was experiencing a decrease in functional ability and weight loss over the past few months.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

LIC9099 (FAS) - (06/04)

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