126803830-9-27-2023-21-AS-BMOS-CX4PFS-20231030111712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 09/26/2023
Date Signed: 09/27/2023 08:35:36 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
09/21/2023 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20230921111857

FACILITY NAME:	SEQUOIA SPRINGS SENIOR LIVING COMMUNITY		FACILITY NUMBER:	126803830
ADMINISTRATOR:	PAMELA CHAPMAN		FACILITY TYPE:	740
ADDRESS:	2401 REDWOOD WAY		TELEPHONE:	(541) 840-4035
CITY:	FORTUNA	STATE: CA	ZIP CODE:	95540
CAPACITY:	92	CENSUS: 62	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Charmin Bailey		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Unlawful Eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 8:30AM, 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, toured the facility, reviewed records and interviewed staff. Based on records reviewed, the facility was aware of resident behaviors upon admission. R1 did not exhibit behaviors for the first few months. When behaviors began, facility did not update care plans or change staffing levels to address the behaviors. The eviction notice indicates certain dates of behaviors, but there is no documentation to show the facility took steps to address the behaviors. LPA reviewed incident reports and other documentation and observed there is no evidence the facility notified the residents responsible party to inform them of these incidents. LPA reviewed the eviction notice and found it lacking information regarding the residents right to contest the eviction...Continued on LIC9099-C...

Substantiated

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: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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 3

Control Number 21-AS-20230921111857

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: 09/26/2023

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

The eviction notice should contain this exact language as directed in regulation 87224(d)(1)(D). The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." LPA observed the eviction notice did not contain the effective date of the eviction as required in regulation 87224(d)(1)(A).

LPA was informed during this visit that the eviction would be rescinded.

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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20230921111857

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: 09/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/20/2023 Section Cited CCR 87224(d)(1)(D)	1 2 3 4 5 6 7	The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4):...This requirement is not met as evidenced by: Based on a review of the eviction notice, Licensee did not include	1 2 3 4 5 6 7	Licensee rescinded the eviction. Licensee to review eviction regulation, which was provided by LPA, and send Self Certification they have read and understood. Self Certification to be submitted by POC date 10/20/2023.
	8 9 10 11 12 13 14	the proper language per regulation.	8 9 10 11 12 13 14
	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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3