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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500567
Report Date: 12/16/2023
Date Signed: 12/16/2023 02:38:56 PM


Document Has Been Signed on 12/16/2023 02:38 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SEQUOIAS-PORTOLA VALLEY, THEFACILITY NUMBER:
410500567
ADMINISTRATOR:APRIL THOMPSONFACILITY TYPE:
741
ADDRESS:501 PORTOLA ROADTELEPHONE:
(650) 851-1501
CITY:PORTOLA VALLEYSTATE: CAZIP CODE:
94028
CAPACITY:328CENSUS: 300DATE:
12/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Facility Staff - Carmen SaldanaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA entered through the main lobby, met with front desk staff, and explained the purpose of the visit. Front desk staff contacted security to escort LPA to the Lodge and the Gardens area of the facility. LPA then met with lead nurse, which contacted Administrator April Thompson. April directed LPA to contact Sue Fairley, Executive Director (ED). ED Fairley appointed Nursing Staff Carmen and Flora to carry out the visit. The current census is 300 for the entire community. For the Assisted Living and Memory Care areas, the census is currently 40.

LPA Valerio and facility staff toured The Gardens and The Lodge to ensure compliance with Title 22 regulations. LPA observed The Gardens. Exit doors were equipped with working alarm systems and required a lock code to exit. LPA observed toxins, cleaning supplies, sharps, and medications locked away and inaccessible to residents in care. Resident bedrooms were observed to be fully furnished. Bathrooms were observed to be clean, sanitary, and have necessary grab bars and hygiene supplies. Hot water temperature was measured to deliver hot water at 112.3*F, which is within the regulatory range of 105-120*F. LPA observed the Activity Director carrying out activities with residents. No health or safety concerns observed for The Gardens.

LPA observed The Lodge side of the facility. Common areas, resident bedrooms, dinning area, medication room, and staff offices were observed. LPA observed residents in their bedrooms, sitting in common areas, walking out to the community, and eating lunch. Hot water temperature was measured at 113.0*F. No health or safety concerns observed for The Lodge. Fire pull alarm system, fire extinguishers, carbon monoxide detector, and fire detectors were observed to be in working condition for both areas of the facility.

Continues on LIC 809 - C...
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SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SEQUOIAS-PORTOLA VALLEY, THE
FACILITY NUMBER: 410500567
VISIT DATE: 12/16/2023
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Continued from LIC 809

LPA reviewed 4 resident files. 4 out of 4 resident files were observed to be out of compliance. A copy of the LIC 811 was provided to staff for ED Sue Fairley for review.

All staff on shift were observed to be fingerprinted and cleared.

LPA Valerio spoke to Administrator April Thompson via cell phone. Administrator April informed LPA Valerio of an Administrator Change. LPA to inform San Bruno Regional Office LPA Jaime Vado and LPM Cara Smith.

LPA Valerio requested the following annual documentation be sent to the San Bruno Regional Office:
    • LIC 500 - Personnel Report
    • LIC 308 - Designation of Facility Responsibility
    • LIC 402 Surety Bond (if applicable)
    • Qualifications of Administrator for ED Sue Fairly
    • LIC 200 - Change of Administrator Application
    • LIC 610E - Emergency Disaster Plan
    • Copy of Liability Insurance

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiences were observed and are being cited today on the attached LIC 809 - D page. Appeal rights were provided. An exit interview was held, and a copy of the report was provided to Nursing staff Flora and Carmen.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/16/2023 02:38 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SEQUOIAS-PORTOLA VALLEY, THE
FACILITY NUMBER: 410500567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review , the licensee did not comply with the section cited above in 4out of 4 resident files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Licensee to ensure all resident files are up to date with necessary information, such as LIC 602, reappraisals, etc. Licensee to send confirmation to the Regional Office that the files have been reviewed and updated with current information by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2023
LIC809 (FAS) - (06/04)
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