Sequoia Springs Senior Living Community

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Administrator Charmin Bailey, interviewed staff and reviewed records. Based on interviews conducted and records reviewed, LPA observed the facility did not ensure laundry is done in a timely manner. LPA reviewed housekeeping records and observed resident laundry is not always completed as agreed to in the admission agreement. LPA observed several occasions where a residents laundry was not completed for more than 2 weeks. Based on records reviewed and interviews conducted, the facility windows are in disrepair. Many resident room windows are not operational. Some do not open correctly or do not close completely. Facility is aware and has a plan to replace the windows in the building but needs to wait for the weather. Continued on LIC9099-C... SubstantiatedRead the full finding— CDSS inspection report, April 5, 2024 · control 21-AS-20231229133708

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Administrator Charmin Bailey interviewed staff and reviewed records. Based on records reviewed, Resident (R1) did not receive medication as ordered. Records show the medication was out of stock, but there was no documentation to show facility followed up. Facility does not have a written procedure to ensure oversight for re-ordering medications. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. This is a repeat violation, civil penalty of $250.00 is being issued. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. ThisRead the full finding— CDSS inspection report, April 5, 2024 · control 21-AS-20240216124504

At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to amend this report to add additional information regarding the above allegations. On 04/05/2024 at approximately 8:30AM, LPA met with Administrator Charmin Bailey and reviewed records. Based on a review of staff training records, facility has documentation of required staff training. LPA observed additional training for special circumstances as well. LPA reviewed facility infection control plan and observed precautions implemented to decrease the risk of infection. Facility was in daily contact with local public health, signs were posted and staff were wearing proper personal protective equipment (PPE). LPA toured facility and did not find evidence to support the allegation that facility is in disrepair. 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 allegatioRead the full finding— CDSS inspection report, April 5, 2024 · control 21-AS-20240205165146

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Administrator Charmin Bailey and reviewed records. Based on records reviewed and interviews conducted, the facility failed to manage medication as prescribed by physician. LPA reviewed medication records and found R1 did not receive medications that were prescribed to them on multiple occasions due to the facility being out of stock and not reordering on time or not being able to find the medications. ***This is a repeat violation in a 12 month period, an immediate civil penalty is being issued in the amount of $250.*** LPA reviewed care plans and after visit summaries related to R1. Based on records reviewed and interviews conducted, facility did not meet residents care needs. Continued on LIC9099-C... SubstantiatedRead the full finding— CDSS inspection report, March 8, 2024 · control 21-AS-20231229133708

At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to amend this report to add additional information regarding the above allegations. On 03/08/2024 at approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Administrator Charmin Bailey and reviewed records. Based on a review of records, facility did not reorder medications causing resident to be without needed medication as required. Based on a review of records and interviews conducted, resident care needs were not met, Resident did not receive showering assistance or laundry assistance as outlined in facility care plan and Admission agreement. These allegations are addressed and citations issued in complaint, 21-AS-20231229133708. SubstantiatedRead the full finding— CDSS inspection report, March 8, 2024 · control 21-AS-20240205165146

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey, interviewed staff and reviewed records. LPA received copies of documents. Based on a review of admission agreement and invoices of cost of care, the facility made an error by charging resident an additional sum of money one time. The error was caught and the money was refunded. The facility is not charging resident for the cost of a pet. This agency has investigated the above allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. UnfoundedRead the full finding— CDSS inspection report, January 23, 2024 · control 21-AS-20231229133708

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Charmin Bailey, interviewed staff and reviewed records. LPA received copies of documents. Based on records reviewed, facility did not follow up on physician orders to provide care for residents wound. On 11/22/2023, facility was notified, via telephone, to clean, dry and apply a bandage to residents toe daily. On 11/27/2023, an order was faxed to the facility to provide the requested wound care. There is no documation of follow up after 11/22/2023 to obtain the written order. A review of residents care plan shows an update to provide care on 11/27/2023. The wound grew progressivly worse in that timespan. This lack of care resulted in resident being sent to the hospital due to an infection and surgical procedure. Continued on LIC9099-C... SubstantiatedRead the full finding— CDSS inspection report, January 23, 2024 · control 21-AS-20231130145710

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey, toured the building and grounds, interviewed staff and reviewed records. LPA received copies of documents. Based on interviews conducted and records reviewed, the facility became aware of several outside lights that were not operational in August of 2023. Executive Director sent a request to multiple companies for repair quotes for repair. Director submitted the received quotes to the corporate office. The lights were repaired in December of 2023. LPA reviewed Resident Council meeting notes and did not observe any reference to a lack of lighting in the Assisted living section of the facility. 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 UnsubRead the full finding— CDSS inspection report, January 9, 2024 · control 21-AS-20240104111022

At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey and reviewed records. Based on records reviewed and interviews conducted, Resident, R1, was their own responsible party. R1 signed their own admission agreement and listed themselves as the person to contact. Based on interviews conducted and records reviewed, facility does not isolate resident in their room. R1 informed the facility that they would like to stay in their room. R1 is ambulatory and is free to move about the facility as they wish. LPA observed the door to R1's room and there was no sign of any locking device that would prevent R1 from leaving their room. Continued on LIC9099-C... UnsubstantiatedRead the full finding— CDSS inspection report, December 18, 2023 · control 21-AS-20231005090206

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey, toured the facility, reviewed records and interviewed staff. LPA received copies of documents. Based on records reviewed, R1 has had several behavioral issues spanning several months. The department investigated a previous complaint, (21-AS-20230706140520) and requested facility to update the care plan for R1. Behaviors continued to occur. LPA reviewed a report submitted by facility on 09/05/2023, which stated R1 would have staff with them anytime R1 was outside of their room. LPA reviewed the current plan of care for R1 and did not observe any notation informing staff to be with R1 while they are out of the room. Continued on LIC9099-C... SubstantiatedRead the full finding— CDSS inspection report, September 26, 2023 · control 21-AS-20230907120843

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Charmin Bailey, toured the facility, reviewed records and interviewed staff. Based on records reviewed, the facility was aware of resident behaviors upon admission. R1 did not exhibit behaviors for the first few months. When behaviors began, facility did not update care plans or change staffing levels to address the behaviors. The eviction notice indicates certain dates of behaviors, but there is no documentation to show the facility took steps to address the behaviors. LPA reviewed incident reports and other documentation and observed there is no evidence the facility notified the residents responsible party to inform them of these incidents. LPA reviewed the eviction notice and found it lacking information regarding the residents right to contest the eviction...Continued on LIC9099-C... SubsRead the full finding— CDSS inspection report, September 26, 2023 · control 21-AS-20230921111857

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigaiton into the above allegations. LPA met with Executive Director Charmin Bailey, toured the facility, reviewed records and interviewed staff. LPA received copies of documents. Based on interviews conducted and records reviewed, residents are checked for wet clothing before and after every meal and periodically throughout the day. Residents in memory care are checked more often. LPA toured the facility on multiple occasions during the course of this investigation. LPA was informed of a particular room where they are having difficulting keeping the resident from soiling the furniture and themselves. Additional cleanings and clothing changes have been ongoing but the resident is resistant. Facility will continue to address the behavior. Continued on LIC9099-C... UnsubstantiatedRead the full finding— CDSS inspection report, August 30, 2023 · control 21-AS-20230707122711

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigaiton into the above allegations. LPA met with Executive Director Charmin Bailey, toured the facility, reviewed records and conducted interviews. LPA reviewed resident care plans and Hospice documentation and found several residents requiring two person assists. LPA reviewed staffing schedules and found certain shifts that did not have proper staffing to meet resident needs. LPA observed memory care only had 1 staff scheduled on certain days. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewRead the full finding— CDSS inspection report, August 30, 2023 · control 21-AS-20230706140520

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigaiton into the above allegations. LPA met with Executive Director Charmin Bailey, toured the facility, reviewed records and interviewed staff. LPA received copies of documents. Based on records reviewed, Facility did not update the care plan for resident, R1, or adjust staffing levels after R1 had numerous incidents of assaulting other residents. The incidents of aggression to other residents have be ongoing for several months. LPA reviewed documentation of staff reporting these events, but there is no documenation of changes made to ensure the safety of other residents. ***This is a repeat violation in a 12 month period. An immediate civil penalty is being issued in the amount of $250.*** Continued on LIC9099-C. SubstantiatedRead the full finding— CDSS inspection report, August 29, 2023 · control 21-AS-20230706140520

At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Charmin Bailey, interviewed staff and reviewed records. During the course of this investigation, LPA interviewed staff and reviewed records regarding the policy of answering the telephone after hours. LPA was informed that in the past, a cordless telephone was accessible to the medication technician to answer the main phone number after hours, but it has not worked in some time. LPA reviewed the resident handbook, provided to new residents upon admission and observed the facility states the main phone number is an option to request assistance if the residents emergency pull cord is not working and the phone will be monitored 24/7 by staff. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. DeRead the full finding— CDSS inspection report, April 21, 2023 · control 21-AS-20230131112009

At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey, interviewed staff and reviewed records. LPA reviewed call log records from November through February to determine the response time for calls of service for resident, R1. There were 104 calls for service for R1 in this time period. The pendant system works by pendant activation by the resident, then staff acknowledge the call, assist the resident then reset the pendant. The time it took for staff to acknowledge, assist then reset the pendant ranged from 13 minutes to 29 minutes for this timeframe. During the course of this investigation, LPA observed meal times ranging from Breakfast to Dinner. LPA observed residents gather at the tables up to 45 minutes before the scheduled time of the meal. LPA observed the meals to be brought to the tables at the approximate time of the schRead the full finding— CDSS inspection report, April 21, 2023 · control 21-AS-20230209160155

At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Charmin Bailey, interviewed staff and reviewed records. Resident, R1, recently moved into the facility and was having difficulties sharing a room with another person. R1 is under a full conservatorship by their POA and was in communication with the facility managment team to move R1 to a private room. The aggreement was made with R1 and their Conservator in the morning to move rooms after lunch and a nap. The aggrement included a celebration including some alcohol. R1 was provided alcohol, 2 beers and a small amount of whiskey at the request of the Conservator. LPA reviewed records and found a physician order for alcohol for R1. LPA conducted interviews with staff involved with the celebration. Based on those interviews, R1 was not drunk and the alcohol was not used to weaken the resolve of R1Read the full finding— CDSS inspection report, April 21, 2023 · control 21-AS-20230407091506

At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey, interviewed staff, toured the building and reviewed records. LPA received copies of documents. At approximately 9:15AM, LPA interviewed staff and learned there were no instances of a resident leaving the facility without a staff escort, if required. Based on interviews conducted, there were a few times a resident walked out the front door, but staff were present and accompanied them while away from the building. Resident was with staff at all times while away from the facility grounds. Based on interviews with the Director, the facility suffered some damage from the earthquake on 12/20/2022. Some of the damage was visible and attended to immediately. Recently the facility became aware of a broken sewer pipe under the building. Facility took immediate action once becoming awareRead the full finding— CDSS inspection report, March 22, 2023 · control 21-AS-20230221135734

At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Executive Director Charmin Bailey, interviewed staff, toured the building and reviewed records. LPA interviewed Business office manager Gage Dupper regarding the aftermath of the earthquake that occurred on 12/20/2022. The facility, along with the entire county, lost electrical power as a result of the earthquake. The facility generator provided emergency power to the facility but does not support the heating system. The Director at the time purchased and rented several portable electric heaters and extra blankets for residents who wanted them. Facility staff conducted 15 minute checks on all residents and provided assistance as needed. LPA reviewed facility documentation regarding evictions. During the Covid pandemic, previous management at the facility made an arrangement with residents to waive the cost of iRead the full finding— CDSS inspection report, March 22, 2023 · control 21-AS-20230223102845

At approximately 08:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegation. LPA met with Executive Nurse Teresa Oliveri, reviewed records and interviewed staff. LPA received copies of documents. Based on a record review, Resident 1, R1, has been declining in health for several months. Records indicate R1 had several falls from December through the end of January and there were no documented changes to the care plan. LPA found documentation showing an alert status for R1 but no further instruction for staff to follow. LPA was not able to associate the falls with a lack of staff, however, there were no updated services plans or appraisals for staff to follow to ensure residents needs were met. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of RegulaRead the full finding— CDSS inspection report, February 10, 2023 · control 21-AS-20230203114826

At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to complete an investigation into the above allegation. LPA met with Executive Nurse Teresa Oliveri, interviewed staff and reviewed records. Based on interviews conducted and records reviewed, there is no evidence to support the allegation that a resident was left soiled for an extended amount of time. Based on interviews conducted regarding the incident in question, resident requested assistance at approximately 9:30PM. Staff on duty was not able to assist by themselves and needed the assistance of the oncoming staff. Resident was then assisted, and was assisted two more times during the night. Based on interviews conducted with staff regarding other interactions, resident does not have good recall of events. 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 alleRead the full finding— CDSS inspection report, February 9, 2023 · control 21-AS-20230125093751

At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to complete an investigation into the above allegation. LPA met with Executive Nurse Teresa Oliveri, interviewed staff and reviewed records. The current Administrator of this facility is Pamela Chapman. The day to day running of the facility is shared by Teresa and another nurse, Erin Ortiz. During this visit, LPA was able to speak with Pamela Chapman on the telephone. LPA provided regulation regarding the duties of the Administrator and the duties required of the Administrator. Although the facility has a dedicated Administrator, based on interviews conducted and documents reviewed, the Administrator is not present at the facility a sufficient number of hours to ensure substantial compliance with regulation. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies areRead the full finding— CDSS inspection report, February 9, 2023 · control 21-AS-20230124133301

At approximately 9:20AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Ken Nunes, reviewed records and interviewed staff. Based on interviews conducted, residents were tested for COVID on 12/16/2022, and upon receiving the results of the test, responsible parties were notified. If the responsible party did not answer, a message was left requesting a return call. LPA received documentation regarding COVID positives in the facility. 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 allegation is Unsubstantiated. UnsubstantiatedRead the full finding— CDSS inspection report, December 21, 2022 · control 21-AS-20221219154112

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Executive Director Ken Nunes, reviewed records and interviewed staff. Based on a review of records and interviews conducted, LPA observed the facility did meet the needs of residents in care. Upon observation of the resident causing self harm by removing a catheter, facility staff immediately contacted emergency personnel and resident was taken to the hospital. Hospital staff treated the injury and returned resident to the facility. Resident caused self harm again upon return and was returned to the hospital. This series of events occurred one more time, then a physician removed it. Facility followed physician orders in the care 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 alRead the full finding— CDSS inspection report, December 21, 2022 · control 21-AS-20221102145517

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility, unannounced, to deliver findings from the investigation into the above allegations. LPA met with Executive Director Jessica Milich. Based on interviews and records reviewed during the course of this investigation, staff do provide assistance to residents in a timely manner. LPA was informed there was 1 day where a WIFI outage was discovered after approximately 45 minutes, where resident pendants were not being answered. Staff were not aware that the system was down. Upon learning of the outage, staff enacted protocol, which is to provide whistles to pre identified residents and to do rounds every 10-15 minutes. LPA reviewed facility menu's for June and July. Regulation requires weekly menus to be available for residents in advance, but facility may change menu options without notice. Facility is to keep a record of meals served for 30 days. Based on a review of facility menu's, the meal opRead the full finding— CDSS inspection report, August 5, 2022 · control 21-AS-20220712084321