126803939-12-1-2022-21-AS-BMOS-CNLPJW-20230131102213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803939
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:20:53 PM

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
11/22/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20221122164910

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: 6	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Amanda Mitchell		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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9

Due to neglect and lack of supervision client sustained an unexplained bruise while in care.

INVESTIGATION FINDINGS:

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At approximately 3:50PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unnounced to conduct an investigation into the above allegation. LPA met with Administrator Amanda Mitchell and reviewed documents. Based on a review of records and interviews conducted, R1 was wearing a scarf that was hanging down too low and R1 tripped and fell, landing on their arm. This fall caused a large bruise. The fall was reported to PACE the day of the fall. R1 agreed with staff to no longer wear the scarf and to use it as a decoration in their room. LPA reviewed video footage of the incident and observed the event as described during interviews. Facility has care staff for each shift to ensure the needs of the residents are met.
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.

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: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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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