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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 07/03/2024
Date Signed: 07/03/2024 11:58:04 AM

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
03/29/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240329143310
FACILITY NAME:SEQUOIA SPRINGS SENIOR LIVING COMMUNITYFACILITY NUMBER:
126803830
ADMINISTRATOR:CHARMIN BAILEYFACILITY TYPE:
740
ADDRESS:2401 REDWOOD WAYTELEPHONE:
(541) 840-4035
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:92CENSUS: DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Erin OrtizTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to meet resident's care needs
Facility failed to observe and report changes in resident's condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Administrator Erin Ortiz, reviewed records and interviewed staff. Based on records reviewed and interviews conducted, LPA did not find evidence to support the allegation that facility failed in meeting the needs of a resident, R1. Records showed R1 was able to manage their own needs and only needed assistance with bathing due to safety reasons. Facility records show numerous attempts by staff to assist resident but resident refused. Documentation showed R1 continued to go against physician orders by drinking alcohol to excess. Based on records reviewed, facility documented changes in R1's condition and notified responsible party of such changes. 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:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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