126803830-10-7-2024-21-AS-VBEI-DA3PKV-20241015112347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 126803830
Report Date: 08/21/2024
Date Signed: 10/07/2024 12:35:48 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
07/31/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20240731114601

FACILITY NAME:	SEQUOIA SPRINGS SENIOR LIVING COMMUNITY		FACILITY NUMBER:	126803830
ADMINISTRATOR:	CHARMIN BAILEY		FACILITY TYPE:	740
ADDRESS:	2401 REDWOOD WAY		TELEPHONE:	(541) 840-4035
CITY:	FORTUNA	STATE: CA	ZIP CODE:	95540
CAPACITY:	92	CENSUS: 84	DATE:	08/21/2024
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Roger Endert		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are restricting access to the residents
Staff do not have planned activities for the residents

INVESTIGATION FINDINGS:

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***Amended report to add information regarding LPA follow up for a fire code violation*** 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. LPA reviewed facility program design, evacuation plans and the fire clearance issued by the Fire Authority. Based on interviews conducted, the courtyard gate in the memory care section of the facility was locked with a key pad lock. Facility recently changed the code to the gate to prevent staff from causally using it as an exit and was in the process of retraining staff on the procedures to use the gate. Facility provided code to the Fire Department for use in an emergency. LPA will address this fire code violation on a case management visit. Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (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-20240731114601

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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LPA reviewed the activity program used by the facility. The facility has an activity schedule for both assisted living and memory care, and LPA observed activities being conducted. LPA discussed with Executive Director the need to have a staff dedicated to be the activities director and not be responsible for other duties that would take away from that responsibility. LPA provided a copy of Regulation 87219, Planned Activities.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (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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