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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803830
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:14:58 PM


Document Has Been Signed on 08/21/2024 01:14 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 COMMUNITYFACILITY NUMBER:
126803830
ADMINISTRATOR:CHARMIN BAILEYFACILITY TYPE:
740
ADDRESS:2401 REDWOOD WAYTELEPHONE:
(541) 840-4035
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:92CENSUS: 84DATE:
08/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Roger EndertTIME COMPLETED:
01:30 PM
NARRATIVE
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At approximately 8:05AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to several Unusual incident reports submitted by the facility. LPA met with Executive Director Roger Endert and reviewed records. LPA received two (2) reports that a medication error had occurred, and two (2) reports of residents leaving the facility without staff assistance.
On 07/31/2024, staff noticed there were two different orders for the same medication and resident, R1, had received both. Facility notified responsible party, physician and pharmacy to correct the error. R1 was monitored for side effects due to the error and none were observed.
On 08/11/2024, resident, R2, was given the wrong medication at the wrong times twice, once in the morning and at noon. Facility notified responsible party, physician and pharmacy to correct the error. R2 was monitored for side effects due to the error. R2 stated they were a little dizzy but was fine a short time later.
***This is the third violation in a 12 month period. An immediate civil penalty is being issued in the amount of $1000 for repeating the same code section in a 12 month period.***
On 06/22/2024, staff observed resident, R3, wandering around in the parking lot of the facility. Staff were able to redirect R3 back into the facility with no further incidents. Staff checked the doors and alarms and initiated more frequent checks for the resident.
On 08/12/2024, staff was returning from their break and observed a resident, R4, across the street from the facility. Staff was able to assist the resident back to the facility. Facility has updated resident care plan to address this behavior.
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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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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Document Has Been Signed on 08/21/2024 01:14 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: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2024
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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Staff responsible was given additional training on medication procedures and facility reviewed their process on entering new orders and verification of exsisting orders. POC cleared during visit.
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Facility did not assist with medications as prescribed. This poses an Immediate Health risk to residents. ***An immediate civil penalty is being issued in the amount of $1000 for this repeated violation.
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Type A
08/22/2024
Section Cited
CCR87705(k)(6)

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87705 Care of Persons with Dementia:(6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility.This
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A review of the physical alert devices was conducted and care plans were updated. Staff were retrained in the observation requirements for residents. POC cleared during visit.
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requirement is not met as evidenced by:Based on records reviewed, 2 residents left the facility without staff knoweldge. This poses an immediate Safety risk to residents in care.
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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: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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