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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126804083
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:50:03 PM


Document Has Been Signed on 05/04/2023 03:50 PM - 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:CARING COMPANIONS CARE HOMEFACILITY NUMBER:
126804083
ADMINISTRATOR:RASMUSSEN, COLLENFACILITY TYPE:
740
ADDRESS:2641 HALL AVETELEPHONE:
(707) 616-5693
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:15CENSUS: 9DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Colleen RasmussenTIME COMPLETED:
04:00 PM
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LPA arrived at this facility unannounced, to conduct a case management visit in regards to two unusual incident reports and two death reports submitted to CCL. LPA met with Administrator Colleen Rasmussen and reviewed records.

Incident 1: Staff heard a loud noise from the room of R1. Staff responded to find R1 sitting on the floor next to their chair. R1 stated they tried to sit in the chair and missed it, landing on the floor. R1 stated they were not in pain at that time. The following day staff took R1 to the hospital as they observed swelling on their arm. R1 was diagnosed with a closed fracture dislocation of the right elbow. Treatment was provided and a cast was applied.

Incident 2: R2 fell in the restroom, hitting their eye on the wall. Staff assisted R2 and applied first aid. R2 was taken to the emergency room and received 3 stiches.

Death 1: R3 was in the hospital at the time of death. Based on a review of their latest physician report, their health was declining and were in poor health. Staff observed R3 having difficulty breathing and contacted emergency personnel to respond. R3 was transported and taken to ICU. Facility staff responded correctly, per regulation, to ensure R3's medical needs were met.

Death 2: Staff observed R4 at breakfast, then in their room watching TV. Staff checked on R4 again and found them unresponsive with no pulse. R4 was in poor health and declining per latest physician report.

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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