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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803830
Report Date: 01/09/2024
Date Signed: 01/09/2024 01:11:45 PM


Document Has Been Signed on 01/09/2024 01:11 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:CHARMIN BAILEYFACILITY TYPE:
740
ADDRESS:2401 REDWOOD WAYTELEPHONE:
(541) 840-4035
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:92CENSUS: 62DATE:
01/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Charmin BaileyTIME COMPLETED:
01:25 PM
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to several SOC 341, Report of Suspected Dependent Adult/Elder Abuse, forms. LPA met with Administrator Charmin Bailey, interviewed staff and reviewed records.
Based on records reviewed, there have been several incidents in the memory care section of the facility between residents. The incidents varied from yelling and pushing to one where a resident fell to the floor and was then kicked by another resident. Staff were nearby at each incident and separated the residents and assessed them for injuries. LPA reviewed care plans and assessments and found the facility has made adjustments to the care plans to prevent these behaviors. LPA reviewed staffing schedules and observed there have been two caregivers and one medication technician present. LPA observed notes posted for staff stating at least one staff should be in the common areas at all times and reminders to redirect residents when needed. LPA received copies of documents.

LPA received an SOC 341 regarding a former staff that was reported to have taken a resident to a bank to withdraw money. The staff left employment in November 2023. The information regarding the bank visit was reported 12/29/2023. LPA received copies of employee file and will request follow up with Law Enforcement.

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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