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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803939
Report Date: 05/27/2022
Date Signed: 05/27/2022 10:41:44 AM


Document Has Been Signed on 05/27/2022 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 11DATE:
05/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
11:00 AM
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At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to a death report submitted to CCL on 04/25/2022. LPA met with care giver Jesse Regnier and reviewed documents. Staff found resident on the floor of their room, unresponsive. Staff immediately contacted emergency personnel and began life saving procedures as they were trained. Emergency personnel arrived and took over. Resident was pronounced deceased at facility. LPA received copies of documents and requested a copy of the death certificate when facility is able to obtain it. Facility followed regulation and notified responsible parties.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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