126803830-6-23-2020-21-AS-CMAZ-BQUT6A-20200623142648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 06/23/2020
Date Signed: 06/23/2020 12:48:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2020 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200203110300

FACILITY NAME:	SEQUOIA SPRINGS SENIOR LIVING COMMUNITY		FACILITY NUMBER:	126803830
ADMINISTRATOR:	ENDERT, ROGER		FACILITY TYPE:	740
ADDRESS:	2401 REDWOOD WAY		TELEPHONE:	(801) 325-0124
CITY:	FORTUNA	STATE: CA	ZIP CODE:	95540
CAPACITY:	92	CENSUS: 51	DATE:	06/23/2020
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Roger Endert		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff failed to meet hygiene needs of resident in care.

Staff provided incorrect medication records to hospital.

Insufficient staff to meet the needs of resident

INVESTIGATION FINDINGS:

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At approximately 11:55AM, Licensing Program Analyst (LPA) Chris Arnhold spoke with Executive Director Roger Endert to deliver findings for the above allegations. This visit is being conducted by telephone due to COVID-19 precautions. LPA reviewed documentation from the facility and hospital regarding R1. Resident has the right to refuse showers and changing clothes. Facility documents each of the refusals. There is no documentation regarding hygiene getting out of hand to cause a problem. The facility uses a MAR that is pre-printed by pharmacy and has resident information on the bottom. Facility does not have a blank MAR in use. LPA requested the medication technician verify what MAR was sent to the hospital. LPA received the verified copy. Hospital records show the same medication listed on the facility MAR with a few additions that were given by the ER.

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: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

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-20200203110300

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SEQUOIA SPRINGS SENIOR LIVING COMMUNITY	FACILITY NUMBER: 126803830
	VISIT DATE: 06/23/2020

NARRATIVE

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There is a medication listed on Hospital documentation with a note stating the doctor is aware of heart rate and BP and would like the medication given as ordered. LPA attempted to contact hospital staff, but they would not provide residents information. There are no notes from the hospital indicating the wrong paperwork was submitted to them from the facility. LPA reviewed staffing schedules and care plans of residents. LPA reviewed care plan and physician report and it states the resident needs assistance and is on 2 hour checks. This does not prevent the resident from attempting to do things on their own. Resident wears depends and uses a walker. The resident is not on a 1 to 1 observation and has the ability to move freely.
Based on interviews conducted and a review of records, the allegations are found to be Unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

No citations issued.

Original signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

LIC9099 (FAS) - (06/04)

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