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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601086
Report Date: 08/06/2025
Date Signed: 08/06/2025 03:35:07 PM

Document Has Been Signed on 08/06/2025 03:35 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:SEQUOIA HOMEFACILITY NUMBER:
415601086
ADMINISTRATOR/
DIRECTOR:		FUJII, ROGERFACILITY TYPE:
735
ADDRESS:1499 SEQUOIA AVENUETELEPHONE:
(415) 279-3128
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
08/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Caregiver, Jefferson RocaberteTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On August 6, 2025, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. Upon arrival, LPA was greeted by caregiver, Jeff Rocaberte and LPA explained the purpose of today's visit. The administrator, Roger Fujii arrived shortly thereafter and assisted with the inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

This is a two story facility. On the ground level, LPA observed four private resident rooms and one office. On the 2nd floor, LPA observed a large staff room that is separated by two privacy curtain into 3 individual spaces. The 2nd floor also has a full bathroom and a closet. LPA observed the resident rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean and in operating condition. Hot water temperature was measured at 105-110 degrees F in the kitchen and resident bathrooms.

LPA observed medications, toxins and sharps to be locked and inaccessible to residents in care. 2 days for perishables and & 7 days non-perishable were observed to be present.

Emergency drill records were reviewed.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/06/2025 03:35 PM - It Cannot Be Edited


Created By: Murial Han On 08/06/2025 at 10:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SEQUOIA HOME
FACILITY NUMBER: 415601086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above In reviewing the criminal background clearance process, LPA observed one of the three adults who resides in the ADU did not have a background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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The administrator will start the criminal background clearance process today and will provide a copy of the documents to CCL by 8/7/2025. A civil penalty of $100 is being assessed today.
Type A
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the review of the resident files, LPA observed resident #2 (R2), resident #3 (R3) and resident #4 (R4) has bed rails by the head of the bed without a written physician's which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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The administrator will develop a plan of correction indicating the facility's action to ensure compliance and the plan shall indicate the date that the order will be obtained. The administrator will provide a copy of the plan to CCL by 8/7/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/06/2025 03:35 PM - It Cannot Be Edited


Created By: Murial Han On 08/06/2025 at 10:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SEQUOIA HOME
FACILITY NUMBER: 415601086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(8)(E)1
Personal Rights
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R2 and R3 also have bed rails by the foot of their beds and both of the resident are not on hospice which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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The administrator will develop a plan to ensure compliance and provide a copy of the plan to CCL by 8/7/2025. If the plan is to remain the bed rails by the head and the foot of the bed, the administrator shall indicate it on the plan of correction and provide all the require documents to CCL by 8/11/2025 to request for an exception.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


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: SEQUOIA HOME
FACILITY NUMBER: 415601086
VISIT DATE: 08/06/2025
NARRATIVE
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During the tour of the facility, LPA observed an Accessary Dwelling Unit (ADU) on the property that is being occupied by a family of four (3 adults and 1 minor); LPA check facility file, and it did not indicate that CCL was notified of such alteration/construction. According to the administrator, the property owner contacted CCL and was told to proceed with the alteration/construction after obtaining approval and permit from the city. However, the administrator stated that the property owner did not remember when CCL was contacted and there was no documentation to proof that CCL was informed.

In reviewing the background clearance process, LPA observed one of the three adults who resides in the ADU did not have a criminal background clearance.

During the review of the resident files, LPA observed resident #2 (R2), resident #3 (R3) and resident #4 (R4) have bed rails by the head of the bed without a written physician's order. In addition, R2 and R3 also have bed rails by the foot of their beds and both of the residents are not on hospice.

The above findings poses/posed a potential and an immediate health, safety or personal rights risk to persons in care.

During today's visit, a civil penalty of $100 is being assessed as one of the individuals who resides in the ADU did not have a background criminal clearance.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties.



This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/06/2025 03:35 PM - It Cannot Be Edited


Created By: Murial Han On 08/06/2025 at 10:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SEQUOIA HOME
FACILITY NUMBER: 415601086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed an ADU on the property and the facility was not able to provide that CCL was notified and there is no records in CCL of such construction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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The administrator will provide a copy of the permit for the ADU, the administrator will provide a revise facility sketch reflecting the change of the building and a written request for a Fire Clearance inspection due to the building alteration and submit it to CCL by 8/13/2025.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
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