126803830-12-21-2022-21-AS-BMOS-CP9PF4-20230221101607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 12/21/2022
Date Signed: 12/21/2022 11:55:05 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
12/19/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20221219154112

FACILITY NAME:	SEQUOIA SPRINGS SENIOR LIVING COMMUNITY		FACILITY NUMBER:	126803830
ADMINISTRATOR:	MILICH, JESSICA		FACILITY TYPE:	740
ADDRESS:	2401 REDWOOD WAY		TELEPHONE:	(541) 840-4035
CITY:	FORTUNA	STATE: CA	ZIP CODE:	95540
CAPACITY:	92	CENSUS: 67	DATE:	12/21/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Ken Nunes		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not keep residents authorized person informed about resident's care

INVESTIGATION FINDINGS:

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At approximately 9:20AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Ken Nunes, reviewed records and interviewed staff. Based on interviews conducted, residents were tested for COVID on 12/16/2022, and upon receiving the results of the test, responsible parties were notified. If the responsible party did not answer, a message was left requesting a return call. LPA received documentation regarding COVID positives in 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 allegation is 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: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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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