126803939-11-8-2022-21-AS-BMOS-CLEN49-20221122090735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803939
Report Date: 11/08/2022
Date Signed: 11/08/2022 09:40:44 AM

Unsubstantiated

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
11/03/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20221103121955

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: 7	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Amanda Mitchell		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Staff pushed resident
Staff inappropriately confiscated residents personal items

INVESTIGATION FINDINGS:

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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Administrator Amanda Mitchell and reviewed video footage for 11/03. LPA observed a resident wandering around and picking up halloween decorations. A staff member took the item from the resident in a safe manner. As the staff was taking the item, the resident turned and began to sit in a reclining chair behind them. The video showed the staff was ready to assist the resident into the chair, but the resident dropped into the chair. LPA reviewed additional video of staff interactions with the resident and found each encounter to be conducted in a safe and respectful manner. 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. No citations issued.

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: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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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