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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 04/21/2023
Date Signed: 04/21/2023 11:35:26 AM

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
01/31/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20230131112009
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: 52DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Charmin BaileyTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility does not answer phone after hours
INVESTIGATION FINDINGS:
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Charmin Bailey, interviewed staff and reviewed records. During the course of this investigation, LPA interviewed staff and reviewed records regarding the policy of answering the telephone after hours. LPA was informed that in the past, a cordless telephone was accessible to the medication technician to answer the main phone number after hours, but it has not worked in some time. LPA reviewed the resident handbook, provided to new residents upon admission and observed the facility states the main phone number is an option to request assistance if the residents emergency pull cord is not working and the phone will be monitored 24/7 by staff.
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 Charmin Bailey 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: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
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
01/31/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20230131112009

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: 52DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Charmin BaileyTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff do not ensure resident's grooming needs are being met.
Staff do not ensure resident is provided linen.
Staff do not ensure resident's room is clean.
Staff do not ensure facility kitchen floor is clean.
Staff do not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey, interviewed staff and reviewed records. During the course of this investigation, LPA interviewed staff that provide grooming assistance for residents. LPA was informed when a resident is assisted, there is a notation made on a log sheet of the completed task. LPA reviewed the daily task logs and found R1 was shaved and showered on a reguler basis. There are notations that resident refused on occasion. LPA toured the memory care section of the facility and found resident beds to be made with all appropriate linens. LPA interviewed staff regarding the process of changing resident linens. LPA was informed the beds are changed as needed but at least once a week. Sometimes residents remove blankets and linens due to dementia. LPA interviewed house keeping staff on the procedures of cleaning resident rooms. 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: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
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-20230131112009
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: 04/21/2023
NARRATIVE
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LPA was informed the memory care section is cleaned on Tuesdays and Fridays or as needed. If a need arises, house keeping staff are notified and they come to address the situation. If a resident has an accident, the caregivers will notify housekeeping, then assist the resident in cleaning up. The house keeping staff will come and clean the area of the accident. During this investigation LPA observed the dining area before, during and after meals. The floors were clean before meals and sometimes messing during meals. The messes were cleaned and the floors were left clean afterwards. LPA observed the tables were wiped clean and sanitized after meals. LPA spoke with staff regarding residents having other resident clothing. Staff told LPA that some residents wander into other resident rooms and put on their clothing. Residents are not on 1 to 1 observation and have freedom to walk around where they wish. Staff redirect residents when they observe them in other rooms, LPA was informed that residents also take things and place them in random places due to their dementia. All clothing articles are labeled with the residents name so items can be returned to their rightful owner.

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: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20230131112009
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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited
CCR
87208(a)
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(a) Each facility shall have and maintain a current, written definitive plan of operation. This requirement is not met as evidenced by: Based on record review, Licensee did not ensure the facility phone is answered
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Licensee to ensure the facility plan of operation is followed. Licensee will update facilities program plan to address telephone coverage and submit to CCL by POC date of 05/19/2023.
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after hours as the resident handbook states. This poses a potential risk to residents in care.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4