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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 12/18/2023
Date Signed: 12/18/2023 03:08:09 PM

Unsubstantiated


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
10/05/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20231005090206
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: 65DATE:
12/18/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Charmin BaileyTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not follow Power of Attorney of resident.
Staff isolates resident in bedroom.
Staff is not communicating with resident's responsible party.
INVESTIGATION FINDINGS:
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey and reviewed records. Based on records reviewed and interviews conducted, Resident, R1, was their own responsible party. R1 signed their own admission agreement and listed themselves as the person to contact.
Based on interviews conducted and records reviewed, facility does not isolate resident in their room. R1 informed the facility that they would like to stay in their room. R1 is ambulatory and is free to move about the facility as they wish. LPA observed the door to R1's room and there was no sign of any locking device that would prevent R1 from leaving their room. Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
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 4
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
10/05/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20231005090206

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:
12/18/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Charmin BaileyTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not transport resident to scheduled medical appointments.
Staff did not allow responsible party to visit in resident's bedroom.
Staff did not provide resident's responsible party with admissions agreement.
Staff is overcharging resident.
INVESTIGATION FINDINGS:
1
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5
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10
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13
At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey and reviewed records. Based on records reviewed and interviews conducted, facility provided transportation to scheduled medical appointments if the resident does not provide their own transporation. R1 arranged transportation to medical appointments through a friend. Based on interviews and records reviewed, R1 informed facility staff they did not wish to visit with certain people in their room. R1 provided facility with a written note to keep in the file. Based on records reviewed, R1 is their own responsible party and received a copy of the admission agreement. LPA reviewed financial documents and the fee schedules for R1. Based on records reviewed, Continued on LIC9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20231005090206
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: 12/18/2023
NARRATIVE
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R1 does not receive additional services from the facility. R1 is being charged the basic rate and has not been charged additional fees while living at the facility.

This agency has investigated the above allegations. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20231005090206
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: 12/18/2023
NARRATIVE
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Based on interviews conducted and records reviewed, the facility abided by the admission agreement and contact information regarding R1. The facility did not disclose information regarding R1 to persons that were not approved by R1.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4