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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803830
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:52:30 PM


Document Has Been Signed on 09/21/2023 02:52 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: DATE:
09/21/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Charmin BaileyTIME COMPLETED:
10:45 AM
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At 10:00AM, Licensing Program Manager (LPM) Bethany Moellers, Licensing Program Analyst (LPA) Chris Arnhold, Executive Director Charmin Bailey and Executive Corporate Nurse, Teresa Oliveri met virtually to discuss areas of concerns with the operation of the facility.

Items discussed included:
-Staffing to ensure residents rights are not violated.
-Reporting requirements.
-Updating resident care plans.
-Staff training regarding resident behaviors.

LPA was informed Administrator on record Pamela Chapman is no longer with the company. LPA requested Licensee to submit documentation of a new Administrator be sent to CCL. Licensee to submit requested documents by 09/29/2023.

LPA Requested the facilities entire Plan of operation. Plan to be submitted to CCL by 09/29/2023.

The Technical Support Program (TSP) was discussed and offered. Executive Director and Executive Nurse agreed the support would be welcome. A referral will be made by LPM.

This report was emailed to the Executive Director for signature. Original signature on file.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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