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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 03/08/2024
Date Signed: 03/08/2024 01:34:42 PM

Substantiated


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
12/29/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20231229133708
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: 64DATE:
03/08/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Charmin BaileyTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility failed to manage medication as prescribed by physician
Staff did not meet residents care needs
INVESTIGATION FINDINGS:
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Administrator Charmin Bailey and reviewed records. Based on records reviewed and interviews conducted, the facility failed to manage medication as prescribed by physician. LPA reviewed medication records and found R1 did not receive medications that were prescribed to them on multiple occasions due to the facility being out of stock and not reordering on time or not being able to find the medications. ***This is a repeat violation in a 12 month period, an immediate civil penalty is being issued in the amount of $250.*** LPA reviewed care plans and after visit summaries related to R1. Based on records reviewed and interviews conducted, facility did not meet residents care needs. Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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
Control Number 21-AS-20231229133708
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care:(4)The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed
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Licensee to provide written procedure that outlines how medications are ordered and how accountability is achieved to ensure medications are available for residents. Written procedure to be submitted to CCL by
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Facility did not assist with medications as prescribed. Facility did not have medications on hand for resident and did not re-order in a timely manner. This poses an Immediate Health risk to residents.
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POC date of 03/11/2024.
Type B
03/29/2024
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical functioning...and that appropriate assistance is provided when such observation
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Licensee to conduct refresher training on how facility monitors and ensures residents are observed for changes. Self certification of completed training to be submitted to CCL by POC date of 03/29/2024.
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reveals unmet needs. This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure the care needs of the resident were met. This poses a potential Health risk to residents.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20231229133708
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: 03/08/2024
NARRATIVE
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Resident did not receive showering assistance or laundry assistance as outlined in facility care plan and Admission agreement. Care plan states staff will monitor and track certain aspects of resident care needs but there is no documentation showing it was done. Based on interviews conducted, resident handles care needs on their own, but care plan indicates care staff are responsible to ensure the needs are met.

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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4