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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803830
Report Date: 07/12/2021
Date Signed: 07/12/2021 04:42:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SEQUOIA SPRINGS SENIOR LIVING COMMUNITYFACILITY NUMBER:
126803830
ADMINISTRATOR:FROST, JEANNAFACILITY TYPE:
740
ADDRESS:2401 REDWOOD WAYTELEPHONE:
(541) 840-4035
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:92CENSUS: 54DATE:
07/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jeanna FrostTIME COMPLETED:
04:45 PM
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At approximately 3:00PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility to conduct a case management visit. LPA met with Executive Director Jeanna Frost. The incident in question occurred on 05/27/2020. Resident received a medication that what not prescribed to them. LPA discussed the incident and learned the staff no longer works at the facility. At the time, staff were retrained and the physician was notified. Resident was placed on alert charting for observation. LPA reviewed staff training practices. Facility is following regulation.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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