126803830-2-9-2023-21-AS-CMAZ-CQBS7M-20230327133745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 02/09/2023
Date Signed: 02/09/2023 04:39:16 PM

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
01/25/2023 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20230125093751

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: 46	DATE:	02/09/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Teresa Oliveri		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff left resident soiled for an extended period of time.

INVESTIGATION FINDINGS:

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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. Based on interviews conducted and records reviewed, there is no evidence to support the allegation that a resident was left soiled for an extended amount of time. Based on interviews conducted regarding the incident in question, resident requested assistance at approximately 9:30PM. Staff on duty was not able to assist by themselves and needed the assistance of the oncoming staff. Resident was then assisted, and was assisted two more times during the night. Based on interviews conducted with staff regarding other interactions, resident does not have good recall of events. 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.

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: 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)

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