126803939-8-16-2023-21-AS-BMOS-CVEN7V-20230906101321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803939
Report Date: 08/16/2023
Date Signed: 08/16/2023 08:43:23 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
06/21/2023 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20230621150330

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:	08/16/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Amanda Mitchell		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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Residents needs not being met

INVESTIGATION FINDINGS:

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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver the results of an investigation into the above allegation. LPA met with Amanda Mitchell. The concerns of this investigation were in relation to Resident 1, R1, leaving the facility in disarray. R1 allegedly was covered in food scraps from breakfast, including on their face, on their shirt and pants and hands. LPA reviewed video footage from the morning in question and although the video did not provide a close up of R1, LPA did not observe food on their person. Interviews conducted with staff on duty, S1, on the morning of the incident, informed LPA that morning was a bit rushed. The bus driver arrived early and was honking their horn for the resident to be brought out. S1 could not recall if they cleaned R1 after breakfast, because R1 was just finishing when the bus arrived. S1 told LPA the normal procedure is to ensure residents are clean and presentable before they leave the facility. 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: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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-20230621150330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 08/16/2023

NARRATIVE

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LPA interviewed Administrator and was informed the normal process after every meal is to ensure the resident is clean and the food residue has been removed. Administrator told LPA there is one bus driver that comes to pick up residents that arrives early and is very impatient. She said the driver will honk repeatedly and it rushes the staff. She told LPA that she has been in contact with the physician for R1 regarding an issue where they pocket food in their mouth and then spit it out later. She said this might have been the cause of the food on their clothing after leaving the facility.

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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC9099 (FAS) - (06/04)

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