126803830-11-20-2023-21-AS-CARD-CXS2TC-20231120164030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 126803830
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:40:37 PM

Document Has Been Signed on 11/20/2023 04:40 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 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:	11/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Charmin Bailey		TIME COMPLETED:	04:55 PM

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	At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Executive Director Charmin Bailey. At approximately 11:15AM, LPA toured the building and grounds which was found to be clean and in good repair. Facility staff were in the process of painting the memory care section of the facility. Staff were present with all painting supplies. A new floor is being installed in the medication room. All medications were relocated to another secure location during the project. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed residents preparing for an activity in the activity room. LPA observed the activity schedule for the day had several activities planned. Toxins are stored in locked storage areas and house keeping carts were secure. LPA tested water temperature at various locations throughout the building. Water temperature measured within regulation between 105 and 120 degrees F. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. LPA inspected the kitchen and food storage areas. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. LPA observed all staff were wearing proper protective equipment for food preparation. At approximately 12:30PM, LPA reviewed 5 staff records. 3 of 5 records did not contain documentation of completed training hours as required. Evidence of current first aid and CPR training were current. Continued on LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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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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
	VISIT DATE: 11/20/2023

NARRATIVE

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At approximately 2:20PM, LPA reviewed the facility emergency disaster plan. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has the required evacuation stair chairs in place. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility does not have documentation of completed disaster drills.

Facility was having an issue with their computer system and LPA was not able to review resident files. LPA will return at a later date to complete this inspection.

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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2023 04:40 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: 11/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(1)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 of 5 records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Licensee to submit written plan to address staff training and the documentation of completed training. Written plan to be submitted to CCL by POC date of 12/20/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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