<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 02/09/2023
Date Signed: 02/09/2023 04:40:13 PM

Substantiated


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
01/24/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20230124133301
FACILITY NAME:SEQUOIA SPRINGS SENIOR LIVING COMMUNITYFACILITY NUMBER:
126803830
ADMINISTRATOR:MILICH, JESSICAFACILITY TYPE:
740
ADDRESS:2401 REDWOOD WAYTELEPHONE:
(541) 840-4035
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:92CENSUS: 48DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Teresa OliveriTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is operating without an Administrator
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to complete an investigation into the above allegation. LPA met with Executive Nurse Teresa Oliveri, interviewed staff and reviewed records. The current Administrator of this facility is Pamela Chapman. The day to day running of the facility is shared by Teresa and another nurse, Erin Ortiz. During this visit, LPA was able to speak with Pamela Chapman on the telephone. LPA provided regulation regarding the duties of the Administrator and the duties required of the Administrator. Although the facility has a dedicated Administrator, based on interviews conducted and documents reviewed, the Administrator is not present at the facility a sufficient number of hours to ensure substantial compliance with regulation. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
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 Teresa Oliveri and Appeal rights were given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
01/24/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20230124133301

FACILITY NAME:SEQUOIA SPRINGS SENIOR LIVING COMMUNITYFACILITY NUMBER:
126803830
ADMINISTRATOR:MILICH, JESSICAFACILITY TYPE:
740
ADDRESS:2401 REDWOOD WAYTELEPHONE:
(541) 840-4035
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:92CENSUS: 48DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Teresa OliveriTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adult allowed to work in the facility with residents
Staff do not ensure that residents are adequately fed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to complete an investigation into the above allegations. LPA met with Executive Nurse Teresa Oliveri, interviewed staff and reviewed records. Based on interviews conducted, the new Maintance Director, S1, was working at the facility while he was waiting for the background clearance to be completed. LPA interviewed staff and was informed that S1 was escorted at all times while in the facility. S1 does not provide any care or supervision and was not left alone with residents. On 02/01/2023, LPA was informed that the background was completed and he was cleared.
On 02/01/2023, LPA spoke with kitchen staff regarding the closure of the kitchen on 01/23/2023. The kitchen was closed to conduct a deep cleaning. In order to ensure residents received dinner, facility ordered food from an outside source and served residents in the dining room. Modified diets were accounted for and food was prepared as ordered. Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20230124133301
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: SEQUOIA SPRINGS SENIOR LIVING COMMUNITY
FACILITY NUMBER: 126803830
VISIT DATE: 02/09/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed facility menus and observed the quality and quantity of meals served at the facility meet regulation.

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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20230124133301
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: SEQUOIA SPRINGS SENIOR LIVING COMMUNITY
FACILITY NUMBER: 126803830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2023
Section Cited
CCR
87405(a)
1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator...and shall be on the premises a sufficient number of hours to permit adequate
1
2
3
4
5
6
7
Licensee to ensure a certified Administrator is present at the facility. Licensee to submit a written plan, including dates and hours, to CCLD outlining how the Licensee will have a Certified and Qualified Administrator
8
9
10
11
12
13
14
attention to the management and administration of the facility. This requirement is not met as evidenced by: Based on interviews conducted, the Administrator is not present at the facility a sufficent number of hours.
8
9
10
11
12
13
14
present at the facility. Written plan to be submitted to CCL by POC date of 03/09/2023.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4