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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803830
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:40:59 PM


Document Has Been Signed on 08/30/2023 02:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
126803830
ADMINISTRATOR:PAMELA CHAPMANFACILITY TYPE:
740
ADDRESS:2401 REDWOOD WAYTELEPHONE:
(541) 840-4035
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:92CENSUS: 61DATE:
08/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Charmin BaileyTIME COMPLETED:
02:45 PM
NARRATIVE
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At approximately 9:30AM, during the course of a complaint investigation, LPA toured the facility and grounds. While walking through the memory care section of the facility, LPA observed the laundry area was unsecured and accessible to residents. LPA inspected the laundry machines and shelves surrounding them. LPA observed a plastic water bottle containing approximately 8 ounces of blue laundry detergent. LPA did not observe any staff in the immediate area. LPA secured the lock to the laundry area and informed staff of the deficiency. At approximately 11:15AM, LPA returned to the memory care section to speak with a Hospice nurse. At approximately 11:45AM, LPA was exiting the secure courtyard and observed a bottle of bubble mixture on a table. LPA asked staff if they could secure the mixture and informed LPA the activities person was using it. LPA did not observe any activities personnel present. LPA went to the Activities office and observed the Activities office door was open and no staff were present. LPA observed the lock on the inside of the door was in the unlocked position. LPA secured the lock and closed the door.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2023 02:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia:(2)...and toxic substances such as...cleaning supplies and disinfectants. This requirement is not
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Licensee to ensure items that could cause harm to residents are secure at all times. Licensee to schedule training regarding Regulation 87705 for all staff working in memory care. Training to be scheduled by POC date
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met as evidenced by:Based on observation, Licensing did not ensure toxic substances were secure and not accessible to residents in care. This poses an immediate Health and Safety risk to residents in care.
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of 08/31/2023. Evidence of completed training, with sign in sheets, to be submitted to CCL by POC date of 09/30/2023.

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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: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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