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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803939
Report Date: 01/27/2025
Date Signed: 01/27/2025 01:25:40 PM

Document Has Been Signed on 01/27/2025 01:25 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:ESPECIALLY YOU ASSISTED LIVING, INC.FACILITY NUMBER:
126803939
ADMINISTRATOR/
DIRECTOR:		MITCHELL, AMANDA L.FACILITY TYPE:
740
ADDRESS:12 HENDERSON STREETTELEPHONE:
(707) 443-8838
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 15CENSUS: 11DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Amanda MitchellTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Amanda Mitchell. At approximately 11:15AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.
At approximately 11:45AM, LPA reviewed 5 of 11 resident records. LPA observed 5 of 5 records did not contain current appraisals. All records contained current and signed admission agreements. Medication records are thorough and contained physician's orders for each resident.
At approximately 12:45PM, LPA reviewed 5 staff records. Documentation of completed training was on file and evidence of first aid and CPR training were current.
At approximately 12:50PM, LPA reviewed the facility emergency disaster plan. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills quarterly.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
Evidence of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Amanda Mitchell and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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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Document Has Been Signed on 01/27/2025 01:25 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 01/27/2025 at 01:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ESPECIALLY YOU ASSISTED LIVING, INC.
FACILITY NUMBER: 126803939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 of 5 resident records. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Licensee to ensure appraisals are updated as needed or at least every 12 months. Licensee to submit self certification that all appraisals have been updated. Self certification to be submitted to CCL by POC date of 02/14/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
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