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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:18:28 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
06/05/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240605141038
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
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Roger EndertTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for a resident
Staff made unauthorized changes to a resident's medical needs
Staff do not provide adequate care and supervision to the residents
INVESTIGATION FINDINGS:
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At approximately 8:05AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegation. LPA met with Executive Director Roger Endert, reviewed records and interviewed staff. Based on interviews conducted, Resident was found on the floor of their apartment at approximately 5:00PM on 05/22/2024. Upon discovery, staff immediately contacted emergency personnel. Resident was admitted to the hospital. Resident was living in the assisted living area of the facility and was not under any close observation orders. Facility procedures are to check on residents approximately every 2 hours. Resident returned from the hospital under the care of a Hospice agency. Based on records reviewed, the physician at the hospital was in communication with the family and the facility regarding the care needs of the resident. Continued on LIC 9099-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: 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.
LIC9099 (FAS) - (06/04)
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Control Number 21-AS-20240605141038
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: 08/21/2024
NARRATIVE
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When resident returned back from the hospital, facility updated the care plan to reflect the new care needs of the resident.

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: 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
LIC9099 (FAS) - (06/04)
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