<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701221
Report Date: 02/06/2025
Date Signed: 02/06/2025 02:13:12 PM

Document Has Been Signed on 02/06/2025 02:13 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PAULSON COMMUNITY - SEQUOIA HOME, THEFACILITY NUMBER:
502701221
ADMINISTRATOR/
DIRECTOR:		HEKIMIAN, VARTANFACILITY TYPE:
735
ADDRESS:2812 PAULSON RD.TELEPHONE:
(559) 577-4239
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY: 4CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:32 PM
MET WITH:Jessica Villasenor, Administrative Team LeadTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a Case Management regarding completed client files. LPA Campbell met with Administrative Team Lead, Jessica Villasenor and explained the purpose of the visit.

During the course of the visit, LPA Campbell requested the files for Sequoia Home. The files for the other three facilities in the community had been reviewed during recent annual inspection visits. During Sequoia Home's annual inspection, LIC 602's were reported to still be at the doctor's office per Jessica Villasenor and could not be reviewed at that time. LPA Campbell asked Jessica Villasenor when the rest of the 602's could be picked up and she replied they could be received in a week.

LPA Campbell returned during today's vist and requested and reviewed the medical files for the two clients at Sequoia Home with missing 602's. Forms were either still missing or incomplete for R1 and R2 per Jessica Villasenor.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiency is being cited on the attached 809-D during this visit. 
An exit interview was conducted, and copies of the report and appeal rights left. 
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/06/2025 02:13 PM - It Cannot Be Edited


Created By: Renee Campbell On 02/06/2025 at 01:10 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAULSON COMMUNITY - SEQUOIA HOME, THE
FACILITY NUMBER: 502701221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2025
Section Cited
CCR
80069(b-c)

1
2
3
4
5
6
7
80069 Clinical Medical Assissment. In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file... the client's medical assessment....The results of an examination for communicable tuberculosis...This requirement is not met as evidenced by....
1
2
3
4
5
6
7
Administrators will become more involved in ensuring client files are complete and will identify a consistent procedure to obtain completed 602's from client doctor's offices. By POC due date, the facility will audit client files using a checklist provided to LPA Campbell and will contact doctor's offices to
8
9
10
11
12
13
14
Based on document review, the licensee had missing or incomplete LIC602 documents for two of four client files reviewed which poses an immediate Health, Safety or Personal, Rights risk to persons in care.
8
9
10
11
12
13
14
establish the steps needed to obtain 602's without delay.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2