126803830-7-23-2025-21-AS-VBEI-DL8Q27-20250905114638

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 07/23/2025
Date Signed: 07/23/2025 01:01:53 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
07/22/2025 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20250722165411

FACILITY NAME:	SEQUOIA SPRINGS SENIOR LIVING COMMUNITY		FACILITY NUMBER:	126803830
ADMINISTRATOR:	ALMA PERALTA		FACILITY TYPE:	740
ADDRESS:	2401 REDWOOD WAY		TELEPHONE:	(707) 726-0111
CITY:	FORTUNA	STATE: CA	ZIP CODE:	95540
CAPACITY:	92	CENSUS: 54	DATE:	07/23/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Alma Peralta		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility not allowing resident visitors

INVESTIGATION FINDINGS:

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At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegation. LPA met with Executive Director Alma Peralta, Interviewed staff and residents, toured the building and reviewed records. LPA received copies of documents. Based on interviews conducted and records reviewed, a former staff who was visiting with residents in the dining room was escorted from the building. The reason given was former staff are not allowed to enter the building or visit with residents without prior permission from the Administrator. This policy violates Health and Safety code, preventing residents to have visitors of their choosing and without prior notice.
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 Alma Peralta and Appeal rights were given.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

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
SANTA ROSA RO, 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
07/22/2025 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20250722165411

FACILITY NAME:	SEQUOIA SPRINGS SENIOR LIVING COMMUNITY		FACILITY NUMBER:	126803830
ADMINISTRATOR:	ALMA PERALTA		FACILITY TYPE:	740
ADDRESS:	2401 REDWOOD WAY		TELEPHONE:	(707) 726-0111
CITY:	FORTUNA	STATE: CA	ZIP CODE:	95540
CAPACITY:	92	CENSUS: 54	DATE:	07/23/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Alma Peralta		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
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8
9

Facility is blocking a fire exit
Facility not following the menu

INVESTIGATION FINDINGS:

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At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Executive Director Alma Peralta, Interviewed staff and residents, toured the building and reviewed records. LPA received copies of documents. Based on interviews conducted and records reviewed and observations made, LPA observed a large kitchen appliance being stored in a hallway near an exit door. The position of the appliance does not block the hallway or exit. There is sufficient space in the remaining hallway to allow exiting in an emergency. LPA reviewed menu's and menu's with marking's to notate changes made. LPA observed there were only four changes made in the calendars reviewed. Regulation allows for changes to resident food service, due to lack of available ingredients and the like, as long as those changes are documented and kept for at least 30 days.
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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

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-20250722165411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 07/23/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/24/2025 Section Cited HSC 1569.269(a)(24)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability:(24) To consent to have relatives and other individuals of the resident’s choosing visit during reasonable hours, privately and without prior notice. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, Licensee	1 2 3 4 5 6 7	Licensee shall review Health and Safety Code section 1569.269 and submit self certification they have reviewed and will abide by the statute. Self Certification shall be submitted to the Department by 07/24/2025. LPA provided copy of Statute for review.
	8 9 10 11 12 13 14	issued a visitor policy that prevented residents visiting with individuals of their choosing without prior notice. This poses an immediate Health, Safety or Personal Rights risk to persons in care.	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.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4