Inspection Reports for Sequoia Springs Senior Living
2401 Redwood Way, Fortuna, CA 95540, United States, CA, 95540
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident safety, and staff training, with several substantiated complaints about inadequate supervision, failure to update care plans, and visitor restrictions. The facility received multiple immediate civil penalties totaling at least $2,250 for repeated medication errors and safety risks, including unsecured toxic substances and insufficient staffing. Several complaint investigations were unsubstantiated, particularly those alleging poor resident care and facility disrepair, though some issues with laundry and building maintenance were substantiated in 2024. The most recent report from September 30, 2025, cited deficiencies involving staff training and medication errors but did not note any fines or enforcement actions. While problems with medication administration and resident safety have recurred, the facility has taken steps such as staff retraining and procedural updates, though challenges remain evident.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
60% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 55
Capacity: 92
Deficiencies: 3
Date: Sep 30, 2025
Visit Reason
The inspection was an unannounced Required-1 Year annual inspection to evaluate compliance with licensing requirements and ensure the health and safety of residents.
Findings
The facility was generally found to be in good condition with no immediate health or safety violations observed during the tour. However, deficiencies were cited related to staff training, medication administration errors, and improper medication storage practices.
Deficiencies (3)
8 of 10 staff files did not contain evidence of completed annual training hours, including dementia care and other required training.
Facility was preparing medication in separate cups before assisting residents, resulting in medication errors.
Staff provided the wrong medication to a resident on three separate occasions.
Report Facts
Residents present during inspection: 55
Total licensed capacity: 92
Medication errors: 3
Staff files reviewed: 10
Staff files lacking required training: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julissa Aguirre | Compliance and Training Coordinator | Met with Licensing Program Analyst during inspection |
| Alma Peralta | Administrator | Facility administrator with current certificate |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kimberley Mota | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 92
Deficiencies: 1
Date: Aug 19, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-08-01 regarding personal rights violations at the facility.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation involved personal rights violations related to refusal to accept a resident back after hospital discharge.
Findings
The investigation substantiated that the facility did not accept a resident back after hospital discharge, violating state laws protecting residents from involuntary transfers and discharges. The resident returned to the facility later receiving hospice care.
Deficiencies (1)
Licensee did not accept resident back to the facility when they were discharged, violating protections against involuntary transfers, discharges, and evictions.
Report Facts
Capacity: 92
Census: 54
Deficiencies cited: 1
Plan of Correction Due Date: Aug 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Peralta | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 1
Date: Aug 19, 2025
Visit Reason
An unannounced complaint investigation was conducted based on a complaint received on 2025-07-31 alleging that facility staff did not dispense medications as prescribed and did not maintain accurate resident records.
Complaint Details
The complaint investigation was substantiated for failure to dispense medications as prescribed, specifically a delay in starting antibiotics for a resident. The allegation regarding inaccurate resident records was unsubstantiated.
Findings
The investigation substantiated that the facility staff failed to start a prescribed antibiotic medication on the correct date, resulting in a delay from 07/19/2025 to 07/21/2025. Another allegation regarding inaccurate resident records was found unsubstantiated due to insufficient evidence.
Deficiencies (1)
Licensee did not ensure resident received assistance with medication as ordered, posing an Immediate Health, Safety or Personal Rights risk to residents in care.
Report Facts
Capacity: 92
Deficiency due date: Aug 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alma Peralta | Administrator / Executive Director | Facility administrator met during investigation and named in findings |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 1
Date: Aug 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including the administrator not responding timely to resident concerns and failure to report a resident fall.
Complaint Details
The complaint investigation was substantiated for the allegation that the administrator did not respond timely to resident concerns. The allegation that the facility did not report a resident fall was unsubstantiated.
Findings
The investigation substantiated that the administrator did not respond in writing to resident council concerns since January 2025, violating Health and Safety Code 1569.157. Another allegation regarding failure to report a resident fall was found unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Failure to respond in writing to resident council concerns within 14 calendar days as required by Health and Safety Code 1569.157.
Report Facts
Facility capacity: 92
Plan of Correction due date: Aug 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Peralta | Administrator / Executive Director | Named in findings related to resident council concerns and complaint investigation |
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 92
Deficiencies: 1
Date: Aug 19, 2025
Visit Reason
The visit was an unannounced case management inspection conducted to review incident reports submitted by the facility regarding residents observed outside the facility without proper supervision.
Complaint Details
The visit was triggered by incident reports of residents observed walking towards the grocery store without proper supervision, requiring staff intervention to return them safely to the facility.
Findings
The inspection found that the facility did not ensure the front exit door was monitored, posing an immediate health, safety, or personal rights risk to residents. Deficiencies were cited related to the lack of auditory or staff alert devices to monitor exits accessible to residents at risk for elopement.
Deficiencies (1)
Licensee did not ensure the front exit door was monitored to ensure the safety of residents, posing an immediate health, safety, or personal rights risk.
Report Facts
Capacity: 92
Census: 54
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Peralta | Executive Director | Met with Licensing Program Analyst during inspection and discussed findings |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 0
Date: Aug 6, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff allowed a minor to administer medications at the facility.
Complaint Details
The complaint alleged that staff allowed a minor to administer medications. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that children often participate in activities during summer months under supervision, but there was no evidence that children assisted with medications or activities of daily living. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 92
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Alma Peralta | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 92
Deficiencies: 1
Date: Jul 23, 2025
Visit Reason
An unannounced complaint investigation was conducted based on a complaint received on 07/22/2025 regarding allegations including the facility not allowing resident visitors, blocking a fire exit, and not following the menu.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility was not allowing resident visitors. The other allegations about blocking a fire exit and not following the menu were unsubstantiated.
Findings
The investigation substantiated the allegation that the facility prevented residents from having visitors of their choosing without prior notice, violating Health and Safety code. Other allegations regarding blocking a fire exit and menu compliance were found unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
To consent to have relatives and other individuals of the resident’s choosing visit during reasonable hours, privately and without prior notice. This requirement is not met as evidenced by a visitor policy preventing residents from visiting with individuals of their choosing without prior notice, posing an immediate Health, Safety or Personal Rights risk.
Report Facts
Capacity: 92
Census: 54
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alma Peralta | Administrator | Facility Administrator met during investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 92
Deficiencies: 2
Date: Jul 2, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not ensure the facility's alert system was properly operating and did not timely respond to residents' alerts.
Complaint Details
The complaint was substantiated. Allegations included failure to ensure the alert system was properly operating and failure to timely respond to resident alerts.
Findings
The investigation found that the facility's call system was not fully operational; calls were received at the front desk but did not directly notify caregivers. After-hours response times often exceeded 20 minutes, posing a potential health and safety risk to residents.
Deficiencies (2)
Licensee did not ensure resident pendant alert system was fully operational, posing a potential Health, Safety or Personal Rights risk to persons in care.
Licensee did not ensure residents received timely assistance as noted in the Resident Handbook, posing a potential Health, Safety or Personal Rights risk to persons in care.
Report Facts
Capacity: 92
Census: 74
Plan of Correction Due Date: Jul 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Peralta | Administrator / Executive Director | Met with Licensing Program Analyst during investigation and discussed findings |
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Census: 75
Capacity: 92
Deficiencies: 0
Date: May 14, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report submitted by the facility regarding a resident found outside the building with an unlocked door and disabled door alarm.
Findings
The inspection found that the door alarm had been left turned off by kitchen staff the day prior, allowing a resident to exit unsupervised. The facility updated procedures to ensure exit alarms are monitored and operational. No citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Peralta | Executive Director | Met with Licensing Program Analyst during inspection and involved in review of incident. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit. |
Inspection Report
Capacity: 92
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
The visit was an unannounced case management inspection conducted due to recent management changes at the facility.
Findings
The Licensing Program Analyst met with the new Executive Director Alma Peralta to discuss reporting requirements and management changes. No citations or deficiencies were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Peralta | Executive Director | Met with Licensing Program Analyst during case management visit regarding management changes. |
| Roger Endert | Former Executive Director | Mentioned as former Executive Director whose last day was 04/09/2025. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 92
Deficiencies: 1
Date: Feb 12, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-01-17 regarding the licensee's failure to issue a refund to a resident's responsible party in a timely manner.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The licensee failed to issue a refund to the resident's responsible party within the required timeframe after the resident's passing and removal of personal belongings.
Findings
The investigation found that the licensee did not issue a refund to the resident's responsible party within the 15-day timeframe required by Title 22 regulation and the Health and Safety Code after the resident's personal belongings were removed. The allegation was substantiated.
Deficiencies (1)
Licensee did not provide a refund within the 15 day timeframe as required by HSC 1569.652(c), posing a potential Personal Rights risk to residents.
Report Facts
Capacity: 92
Census: 61
Deficiencies cited: 1
Plan of Correction Due Date: Feb 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Roger Endert | Executive Director | Facility administrator met during investigation and named in findings |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 62
Capacity: 92
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
The visit was an unannounced case management inspection conducted due to a report that the facility was having difficulty acquiring food items and was unable to report incidents as required.
Findings
The Licensing Program Analyst found that the facility had not had access to their computer records system since January 1 due to a new management company takeover. Handwritten documentation was being used for medications and incident reports. The facility food stores were within regulation, and food was being purchased locally while securing food vendors. No citations were issued during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and made observations regarding documentation and food stores. |
| Jennifer Larue | Met with the Licensing Program Analyst and provided information about documentation and food acquisition. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 92
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-12-17 regarding staff behavior and handling of resident pendants.
Complaint Details
The complaint involved allegations that staff made inappropriate comments regarding a resident and mishandled residents' pendants. The investigation was unsubstantiated due to lack of evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations that staff made inappropriate comments or mishandled resident pendants. One incident involved a pendant being left off a resident for approximately 4 hours without issues.
Report Facts
Complaint Allegations: 2
Pendant off resident duration (hours): 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Roger Endert | Executive Director | Facility administrator met during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 68
Capacity: 92
Deficiencies: 2
Date: Nov 5, 2024
Visit Reason
The inspection was an unannounced Required-1 Year inspection conducted to ensure the health and safety of residents in care and to follow up on a previously reported incident involving medication errors.
Complaint Details
The inspection included a follow-up on an incident report submitted on 10/30/2024 regarding two medication errors that occurred on 10/24/2024 and 10/25/2024. Staff misread medication orders, and an investigation was conducted with staff retraining. This was a repeat violation within 12 months. An immediate civil penalty of $1000 was issued.
Findings
The facility was generally found to be clean, well-maintained, and compliant with health and safety standards, with no immediate violations observed. However, deficiencies were noted related to medication administration errors and incomplete staff training documentation.
Deficiencies (2)
Facility did not assist with medications as ordered, posing an immediate health, safety or personal rights risk to persons in care.
7 out of 10 staff files reviewed did not contain evidence of completed annual training, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Civil penalty amount: 1000
Staff files reviewed: 10
Resident files reviewed: 10
Staff files lacking annual training: 7
Capacity: 92
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roger Endert | Executive Director | Met with Licensing Program Analyst during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 66
Capacity: 92
Deficiencies: 1
Date: Oct 7, 2024
Visit Reason
The visit was an unannounced case management follow-up to amend a prior complaint investigation regarding allegations that staff were restricting residents' access.
Complaint Details
The visit was related to a complaint alleging staff restricted access to residents. The allegation was not substantiated, but a related safety issue was identified.
Findings
The complaint investigation found no evidence that staff restricted access to residents, but identified a safety issue where a new emergency gate code was changed without timely notification to staff or the Fire Department, posing an immediate safety risk. The code was subsequently changed again and all relevant parties were informed.
Deficiencies (1)
Licensee did not ensure staff or Fire Department was informed of a new code for an emergency exit, posing an immediate safety risk to persons in care.
Report Facts
Capacity: 92
Census: 66
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roger Endert | Executive Director | Spoke with Licensing Program Analyst regarding emergency gate code change |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and complaint investigation |
| Bethany Moellers | Licensing Program Manager | Report reviewer and supervisor |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 92
Deficiencies: 2
Date: Aug 21, 2024
Visit Reason
The inspection was an unannounced case management visit conducted in response to several unusual incident reports submitted by the facility, including medication errors and residents leaving the facility without staff assistance.
Complaint Details
The visit was complaint-related due to reports of medication errors and residents leaving the facility without staff assistance. It was noted this was the third violation in a 12-month period, resulting in an immediate civil penalty of $1000.
Findings
The inspection found repeated medication errors involving residents receiving incorrect medications or dosages, and incidents of residents wandering off or leaving the facility without staff knowledge. Immediate civil penalties were issued for repeated violations and deficiencies were cited related to medication assistance and resident safety.
Deficiencies (2)
Facility did not assist with medications as prescribed, posing an immediate health risk to residents.
Facility staff failed to ensure the continued safety of residents with dementia who wandered away from the facility, posing an immediate safety risk.
Report Facts
Civil penalty amount: 1000
Number of medication error reports: 2
Number of residents leaving facility without staff knowledge: 2
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Roger Endert | Executive Director | Met with Licensing Program Analyst during the inspection. |
| Charmin Bailey | Administrator/Director | Facility administrator named in the report header. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 92
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff failed to meet residents' care needs.
Complaint Details
The complaint was unsubstantiated after investigation. The allegation was that facility staff failed to meet residents' care needs, but there was insufficient evidence to prove the violation occurred.
Findings
The investigation found a resident with feces on their body, a swollen ankle, and bruising on their eye. Emergency personnel were contacted and the resident was taken to the hospital. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 92
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Roger Endert | Executive Director | Met with Licensing Program Analyst during investigation |
| Charmin Bailey | Administrator | Facility administrator named in report header |
| Bethany Moellers | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 92
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not seek timely medical attention for a resident, made unauthorized changes to a resident's medical needs, and did not provide adequate care and supervision to residents.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that a resident was found on the floor and emergency personnel were contacted immediately. The resident was hospitalized and returned under hospice care with updated care plans. There was insufficient evidence to substantiate the allegations, and therefore the complaint was unsubstantiated.
Report Facts
Capacity: 92
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Roger Endert | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 92
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were restricting access to residents and that staff did not have planned activities for the residents.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found that the courtyard gate in the memory care section was locked with a keypad lock to prevent casual use by staff, with the fire department having emergency access. The facility has an activity schedule and observed activities being conducted. There was no preponderance of evidence to substantiate the allegations, so they were deemed unsubstantiated.
Report Facts
Capacity: 92
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Roger Endert | Executive Director | Met with Licensing Program Analyst during the investigation |
| Charmin Bailey | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility failed to meet a resident's care needs and failed to observe and report changes in the resident's condition.
Complaint Details
The complaint was unsubstantiated based on records and interviews. Although the allegations may have occurred, there was not a preponderance of evidence to prove violations.
Findings
The investigation found no evidence to support the allegations. Records showed the resident was able to manage their own needs with assistance only for bathing, and the facility documented changes in the resident's condition and notified the responsible party. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Erin Ortiz | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2024-05-06 regarding inadequate care, supervision, and lack of a qualified administrator at the facility.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found that residents have the right to walk freely and staff were aware of resident locations and able to redirect them. The facility administrator position was vacant for about 30 days but oversight was maintained by corporate management and department heads. All staff had received emergency disaster plan training. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Erin Ortiz | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 92
Deficiencies: 2
Date: Apr 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including staff leaving feces-soiled linens in a resident's room for over a week and the facility being in disrepair.
Complaint Details
The complaint investigation was substantiated for allegations related to laundry service delays and facility disrepair. Other allegations regarding portable oxygen and care plan documentation were unsubstantiated.
Findings
The investigation substantiated that the facility did not ensure laundry was done in a timely manner, with resident laundry sometimes not completed for more than two weeks. The facility windows were found to be in disrepair, with many not operational or not closing properly. Other allegations related to oxygen use and care plan documentation were unsubstantiated.
Deficiencies (2)
Licensee did not ensure resident laundry was completed, leaving soiled items in resident rooms for long periods of time, posing a potential health risk.
Licensee did not ensure windows in the building were in good repair; several rooms had windows not in good repair causing potential health or safety risk. This is a repeat violation with a civil penalty.
Report Facts
Capacity: 92
Census: 57
Civil penalty: 250
Plan of Correction Due Date: Apr 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
| Charmin Bailey | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 92
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-02-05 regarding staff training, infection control, and facility disrepair.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations regarding staff training, infection control, and facility condition.
Findings
The investigation found that the facility had documentation of required staff training, was following its infection control plan with proper precautions, and was not in disrepair. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 92
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Charmin Bailey | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 92
Deficiencies: 1
Date: Apr 5, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that resident medication was not administered per regulation.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The facility failed to administer medication as ordered and lacked procedures for medication re-ordering. A civil penalty of $250.00 was issued.
Findings
The investigation found that a resident did not receive medication as ordered because the medication was out of stock and the facility lacked a written procedure to ensure oversight for re-ordering medications. The allegation was substantiated and a repeat violation was noted with a civil penalty issued.
Deficiencies (1)
Licensee failed to assist residents with self-administered medications as needed, specifically failing to ensure medication was re-ordered in a timely manner, posing an immediate health or safety risk.
Report Facts
Civil penalty amount: 250
Plan of Correction due date: Apr 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Charmin Bailey | Administrator | Facility administrator met with during investigation |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 92
Deficiencies: 2
Date: Mar 8, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility failed to manage medication as prescribed by a physician and that staff did not meet residents' care needs.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to manage medication as prescribed and failure to meet residents' care needs. An immediate civil penalty of $250 was issued for repeat medication management violations within 12 months.
Findings
The investigation substantiated that the facility failed to manage medications properly, including not having medications on hand and not reordering them timely, posing an immediate health risk. Additionally, the facility did not meet residents' care needs, including lack of showering and laundry assistance as outlined in care plans.
Deficiencies (2)
Facility did not assist with medications as prescribed; medications were not on hand and not reordered timely, posing an immediate health risk to residents.
Facility did not ensure residents were regularly observed for changes in physical functioning and did not meet care needs, posing a potential health risk.
Report Facts
Civil penalty amount: 250
Plan of Correction due date: Mar 11, 2024
Plan of Correction due date: Mar 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Charmin Bailey | Facility representative met during investigation and involved in findings discussion | |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 92
Deficiencies: 2
Date: Mar 8, 2024
Visit Reason
Unannounced investigation of a complaint received on 2024-02-05 regarding facility mismanagement of medications and unmet resident care needs.
Complaint Details
Complaint investigation was substantiated regarding medication mismanagement and unmet resident care needs.
Findings
The investigation found that the facility did not reorder medications causing residents to be without needed medication, and residents did not receive showering or laundry assistance as outlined in care plans and admission agreements. These allegations were substantiated and citations issued.
Deficiencies (2)
Facility did not reorder medications causing resident to be without needed medication.
Resident care needs were not met; resident did not receive showering or laundry assistance as outlined in care plan and admission agreement.
Report Facts
Capacity: 92
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Charmin Bailey | Administrator | Met with Licensing Program Analyst during investigation. |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 1
Date: Jan 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was not receiving wound care as needed.
Complaint Details
The complaint was substantiated regarding failure to provide wound care, but unsubstantiated regarding failure to provide hygiene care and transportation assistance.
Findings
The investigation found that the facility failed to follow up on physician orders to provide wound care, resulting in the resident's wound worsening and requiring hospitalization and surgery. Other allegations regarding hygiene care and transportation assistance were unsubstantiated due to lack of evidence.
Deficiencies (1)
Licensee did not ensure wound care was provided to resident, posing an immediate health risk.
Report Facts
Capacity: 92
Census: 62
Deficiencies cited: 1
Plan of Correction Due Date: Jan 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation and reviewed findings. |
| Pamela Chapman | Administrator | Facility administrator named in the report header. |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 0
Date: Jan 23, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility was incorrectly charging a resident for a pet they do not have at the facility.
Complaint Details
The complaint was found to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.
Findings
The investigation found that the facility made a one-time billing error by charging a resident an additional sum of money, but the error was caught and refunded. The complaint was determined to be unfounded as the facility is not charging residents for pets.
Report Facts
Capacity: 92
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Pamela Chapman | Administrator | Named as facility administrator |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to several SOC 341 reports of suspected dependent adult/elder abuse involving incidents between residents in the memory care section.
Complaint Details
The visit was triggered by multiple SOC 341 reports of suspected abuse. The allegations included resident altercations and a former staff member's inappropriate conduct involving a resident's finances. Follow-up with law enforcement was planned. No citations were issued during this visit.
Findings
Several incidents involving resident altercations were documented, including yelling, pushing, and one resident being kicked after a fall. Staff were present during incidents and took action to separate and assess residents. Care plans were adjusted to prevent further behaviors, and staffing levels were reviewed. An additional concern involved a former staff member reportedly taking a resident to withdraw money from a bank.
Report Facts
Capacity: 92
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charmin Bailey | Administrator | Met with Licensing Program Analyst during the visit and involved in case management |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility is in disrepair.
Complaint Details
The complaint was unsubstantiated after investigation. The facility was aware of lighting issues and took steps to repair them, but there was insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found that several outside lights were not operational in August 2023 but were repaired by December 2023. Resident Council meeting notes did not reference lighting issues. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 92
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 92
Deficiencies: 0
Date: Dec 18, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2023-10-05 regarding staff not following the Power of Attorney, isolating a resident, lack of communication with the resident's responsible party, failure to transport resident to medical appointments, restricting visits, not providing admission agreements, and overcharging.
Complaint Details
The complaint investigation was unsubstantiated, meaning the allegations were false, could not have happened, or lacked reasonable basis.
Findings
The investigation found that the resident was their own responsible party, was not isolated, and was free to move about. The facility provided transportation when needed, respected visitation preferences, provided admission agreements, and did not overcharge. The complaint was determined to be unsubstantiated as there was no preponderance of evidence to prove the allegations.
Report Facts
Capacity: 92
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Pamela Chapman | Administrator | Facility administrator mentioned in report header |
Inspection Report
Annual Inspection
Census: 62
Capacity: 92
Deficiencies: 1
Date: Dec 4, 2023
Visit Reason
The visit was an unannounced continuation of the annual required inspection conducted on 11/20/2023 to evaluate compliance with regulations.
Findings
The facility was found to have current medication and physician orders, adequate staffing, and implemented a new procedure for monthly emergency drills. However, a deficiency was cited for failure to document completed emergency drills as required by regulation.
Deficiencies (1)
Failure to document completed emergency drills as required by California Code of Regulations section 1569.695(c), posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Capacity: 92
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervised the inspection and named in the report |
Inspection Report
Annual Inspection
Census: 62
Capacity: 92
Deficiencies: 2
Date: Nov 20, 2023
Visit Reason
An unannounced annual required inspection of the licensed senior care facility was conducted to evaluate compliance with regulatory standards.
Findings
The facility was found to be clean and in good repair with proper safety measures in place, including unobstructed exits, proper storage of toxins, and functioning fire safety equipment. However, 3 of 5 staff records reviewed did not contain documentation of completed training hours as required, and the facility lacked documentation of completed disaster drills. Resident files could not be reviewed due to a computer system issue, requiring a return visit.
Deficiencies (2)
3 of 5 staff records did not contain documentation of completed training hours as required.
Facility does not have documentation of completed disaster drills.
Report Facts
Staff records reviewed: 5
Staff records deficient: 3
Capacity: 92
Census: 62
Plan of Correction Due Date: Dec 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Capacity: 92
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
The visit was an unannounced office meeting to discuss possible financial concerns with the facility, including requests for current lease agreements, management/operating agreements, and staffing plans related to vacancies.
Findings
The report documents a meeting involving multiple management and council representatives to address financial concerns at the facility. No specific deficiencies or violations are detailed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Chapman | Administrator | Named as facility administrator |
| Pam Gill | Assistant Program Administrator | Present at meeting discussing financial concerns |
| Alycia Berryman | Regional Manager Sacramento North | Present at meeting discussing financial concerns |
| Carla Nuti-Martinez | Regional Manager Santa Rosa, LPA | Present at meeting discussing financial concerns |
| Christopher Arnhold | Licensing Program Analyst | Present at meeting and named as licensing program analyst |
| Mike Morris | CEO Lenity Management | Present at meeting discussing financial concerns |
Inspection Report
Census: 62
Capacity: 92
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The inspection was an unannounced Health and Safety inspection conducted to ensure the facility is staffed appropriately, staff are being paid, utilities are functioning, and food is plentiful. The visit was prompted by information that the licensee might be experiencing financial hardships.
Findings
No immediate health and safety concerns were observed during the visit. The facility had required amounts of food stored properly, utilities were functioning except for a non-operational exhaust fan above the stove which is scheduled for repair. No issues with staff paychecks were reported. Work on earthquake-damaged areas was ongoing.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during inspection and provided information about the facility. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 1
Date: Sep 26, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of unlawful eviction at Sequoia Springs Senior Living Community.
Complaint Details
The complaint investigation was substantiated based on the preponderance of evidence standard. The allegation involved unlawful eviction and failure to comply with eviction notice regulations.
Findings
The investigation found that the facility did not update care plans or staffing levels to address resident behaviors and failed to notify the resident's responsible party of incidents. The eviction notice lacked required information regarding the resident's right to contest the eviction and did not include the effective date of eviction. The allegation was substantiated and the eviction was rescinded.
Deficiencies (1)
The eviction notice did not include the proper language as specified in Health and Safety Code Section 1569.683(a)(4) and did not contain the effective date of the eviction as required by regulation 87224(d)(1)(A).
Report Facts
Capacity: 92
Census: 62
Deficiency count: 1
Plan of Correction Due Date: Oct 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation report |
| Charmin Bailey | Executive Director | Facility representative met during investigation and review of findings |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 3
Date: Sep 26, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations including inadequate supervision resulting in resident altercations, failure to follow reporting requirements, and a dementia resident having access to a lighter.
Complaint Details
The complaint investigation was substantiated. Allegations included inadequate supervision leading to resident altercations, failure to follow reporting requirements, and a dementia resident having access to a lighter. The facility failed to notify the local Ombudsman and responsible party of incidents due to sending information to a wrong fax number and other notification lapses.
Findings
The investigation substantiated that staff did not provide adequate supervision to prevent a resident from hitting another, the facility failed to notify the responsible party and local Ombudsman of incidents, and a dementia resident had access to a lighter. Some allegations were unsubstantiated due to lack of preponderance of evidence.
Deficiencies (3)
Facility did not ensure staff were present to prevent resident attacking another resident, posing an immediate safety risk.
Resident with dementia had access to lighters, posing an immediate safety risk.
Facility failed to notify responsible party of several incidents within required timeframe.
Report Facts
Facility capacity: 92
Census: 62
Deficiency count: 3
Plan of Correction due dates: Sep 27, 2023
Plan of Correction due dates: Oct 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
| Charmin Bailey | Executive Director | Facility representative met during investigation and involved in discussion of findings |
Inspection Report
Capacity: 92
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
The visit was an office meeting held to discuss areas of concern with the operation of the facility, including staffing, reporting requirements, resident care plans, and staff training regarding resident behaviors.
Findings
The report notes that the Administrator on record is no longer with the company and requests submission of documentation for a new Administrator and the facility's entire Plan of Operation by 09/29/2023. The Technical Support Program was discussed and offered, with agreement from the Executive Director and Executive Nurse.
Report Facts
Capacity: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Chapman | Administrator | Named as the Administrator on record who is no longer with the company |
| Charmin Bailey | Executive Director | Met virtually during the visit and agreed to Technical Support Program |
| Teresa Oliveri | Executive Corporate Nurse | Met virtually during the visit and agreed to Technical Support Program |
| Bethany Moellers | Licensing Program Manager | Conducted the visit and made referrals |
| Christopher Arnhold | Licensing Program Analyst | Conducted the visit and requested documentation |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 92
Deficiencies: 1
Date: Aug 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to a complaint received on 07/06/2023 regarding insufficient staffing at the facility.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard after review of care plans, staffing schedules, and interviews. The allegation was insufficient staffing.
Findings
The investigation found that staffing levels were insufficient to meet resident needs, including memory care shifts with only one staff member scheduled. The allegation of insufficient staffing was substantiated, posing an immediate health, safety, or personal rights risk to residents.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide the services necessary to meet resident needs, violating CCR 87411(a).
Report Facts
Capacity: 92
Census: 61
Deficiency count: 1
Plan of Correction Due Date: Aug 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Pamela Chapman | Administrator | Named as facility administrator |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 92
Deficiencies: 0
Date: Aug 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 07/07/2023 regarding resident care concerns including unattended residents in wet clothing, facility malodor, and failure to meet residents' needs.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that residents are regularly checked for wet clothing and additional cleanings are provided for resistant residents. The facility updated care plans as needed. There was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 92
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Pamela Chapman | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 92
Deficiencies: 1
Date: Aug 30, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation to assess the safety and security of the facility, specifically regarding access to potentially hazardous substances and unsecured areas.
Complaint Details
The visit was complaint-related and involved observations of unsecured toxic substances and unsecured areas accessible to residents. The report does not explicitly state substantiation status.
Findings
The Licensing Program Analyst observed unsecured access to the laundry area containing toxic substances such as laundry detergent accessible to residents, as well as unsecured activities office and materials. These conditions posed an immediate health and safety risk to residents.
Deficiencies (1)
Based on observation, Licensing did not ensure toxic substances were secure and not accessible to residents in care, posing an immediate health and safety risk.
Report Facts
Capacity: 92
Census: 61
Plan of Correction Due Date: Aug 31, 2023
Plan of Correction Training Submission Date: Sep 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charmin Bailey | Met with Licensing Program Analyst during inspection and reviewed report | |
| Bethany Moellers | Licensing Program Manager | Supervisor named in report |
| Christopher Arnhold | Licensing Program Analyst | Licensing evaluator who conducted inspection and signed report |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 92
Deficiencies: 3
Date: Aug 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/06/2023 regarding failure to protect residents, unmet resident needs, and facility cleanliness and disrepair.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to protect residents, unmet resident needs, and facility disrepair. The investigation found evidence supporting these allegations, including repeated resident assaults without care plan updates, medication errors, and facility maintenance issues.
Findings
The investigation substantiated multiple allegations including failure to update care plans and staffing after resident assaults, failure to administer physician-ordered medication for three consecutive days, and facility cleanliness and maintenance issues such as dirty carpets and flaking ceiling paint. Some allegations related to facility construction impacting resident activities were unsubstantiated.
Deficiencies (3)
Licensee did not update resident appraisal after several assaults on other residents, posing an immediate health and safety risk.
Licensee did not ensure resident received physician ordered medication for 3 consecutive days, posing an immediate health risk.
Licensee did not ensure facility was clean and in good repair; carpets were unclean and ceiling paint was flaking.
Report Facts
Civil penalty amount: 250
Capacity: 92
Census: 60
Plan of Correction Due Date: Aug 30, 2023
Plan of Correction Due Date: Sep 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation and was involved in review of findings. |
Inspection Report
Census: 63
Capacity: 92
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The visit was an unannounced case management visit conducted by the Licensing Program Analyst to review records and discuss regulations regarding background checks and resident councils.
Findings
No citations were issued during this visit. The Licensing Program Analyst requested submission of specific documents including LIC 500, staff schedules for June, and actual worked staff hours for June by 07/17/2023.
Report Facts
Capacity: 92
Census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during the visit |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit |
| Bethany Moellers | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including the facility not answering the phone after hours and concerns about resident grooming, linen provision, room cleanliness, kitchen floor cleanliness, and safeguarding of personal belongings.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility does not answer the phone after hours. Other allegations related to resident grooming, linen provision, room cleanliness, kitchen floor cleanliness, and safeguarding personal belongings were unsubstantiated.
Findings
The allegation that the facility does not answer the phone after hours was substantiated, with evidence showing the cordless phone for after-hours calls was not working, posing a potential risk to residents. Other allegations regarding grooming, linen, room cleanliness, kitchen floor cleanliness, and safeguarding personal belongings were investigated but found unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Each facility shall have and maintain a current, written definitive plan of operation. This requirement is not met as evidenced by: Licensee did not ensure the facility phone is answered after hours as the resident handbook states, posing a potential risk to residents in care.
Report Facts
Capacity: 92
Census: 52
Deficiencies cited: 1
Plan of Correction Due Date: May 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Jessica Milich | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 0
Date: Apr 21, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not meeting the care needs of residents and were not serving residents food in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the allegations that staff were not meeting care needs or serving food timely.
Findings
The Licensing Program Analyst found no evidence to support that meals were served late and interviews did not support the allegations. There was not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations were unsubstantiated.
Report Facts
Calls for service: 104
Capacity: 92
Census: 52
Response time range (minutes): 13
Response time range (minutes): 29
Meal wait time (minutes): 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Pamela Chapman | Administrator | Facility administrator named in the report header |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 0
Date: Apr 21, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff used alcohol to persuade a resident while in care.
Complaint Details
The complaint alleged staff used alcohol to persuade a resident while in care. The allegation was unsubstantiated after investigation.
Findings
The investigation found that the resident was provided alcohol as part of an agreed celebration with their conservator, supported by a physician's order. Interviews and observations indicated the resident was not intoxicated and the alcohol was not used to weaken their resolve. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 92
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Pamela Chapman | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 92
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that a resident eloped from the facility and that the facility failed to keep the building and grounds safe and sanitary.
Complaint Details
The complaint was unsubstantiated based on the investigation findings and evidence reviewed.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff interviews and document reviews indicated residents were accompanied by staff when leaving the facility, and the facility promptly addressed damage from an earthquake and a broken sewer pipe.
Report Facts
Capacity: 92
Census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Pamela Chapman | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 92
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations including a resident room without heat for 2 days and unlawful eviction.
Complaint Details
The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations did or did not occur.
Findings
The investigation found that the facility lost electrical power due to an earthquake, and the heating system was not supported by the emergency generator. Portable heaters and blankets were provided, and staff conducted frequent resident checks. Documentation regarding a waiver of in-room meal costs was missing, leading to an eviction notice that was later rescinded with a revised plan agreed upon. The allegations were unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 92
Census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Charmin Bailey | Executive Director | Met with Licensing Program Analyst during investigation |
| Gage Dupper | Business Office Manager | Interviewed regarding earthquake aftermath and facility operations |
| Pamela Chapman | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 92
Deficiencies: 1
Date: Feb 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of lack of supervision resulting in multiple falls at the facility.
Complaint Details
The complaint was substantiated. The allegation was lack of supervision resulting in multiple falls. The investigation included record reviews and staff interviews, concluding that care plans and appraisals were not updated following multiple falls of Resident 1.
Findings
The investigation found that Resident 1 had multiple falls from December through January without updated care plans or service appraisals for staff to follow. The allegation was substantiated based on the preponderance of evidence, indicating a failure to update resident appraisals and care plans, posing a potential health and safety risk.
Deficiencies (1)
Failure to update resident appraisal after several injury falls, posing a potential health and safety risk to residents.
Report Facts
Deficiencies cited: 1
Capacity: 92
Census: 49
Plan of Correction Due Date: Mar 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Teresa Oliveri | Executive Nurse | Met with the Licensing Program Analyst during the investigation |
| Jessica Milich | Administrator | Facility administrator named in the report header |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 92
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including the facility operating without an Administrator, an uncleared adult working with residents, and inadequate feeding of residents.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility was operating without an Administrator present for sufficient hours. The allegations that an uncleared adult was allowed to work and that residents were not adequately fed were unsubstantiated.
Findings
The allegation that the facility was operating without an Administrator was substantiated due to the Administrator not being present a sufficient number of hours to ensure compliance. The allegation regarding an uncleared adult working was unsubstantiated as the individual was escorted at all times and did not provide care. The allegation that residents were not adequately fed was unsubstantiated as the kitchen closure was temporary and residents received appropriate meals.
Deficiencies (1)
87405 Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. This requirement is not met as evidenced by: Based on interviews conducted, the Administrator is not present at the facility a sufficient number of hours.
Report Facts
Capacity: 92
Census: 48
Deficiencies cited: 1
Plan of Correction Due Date: Mar 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Teresa Oliveri | Executive Nurse | Met with Licensing Program Analyst during investigation |
| Pamela Chapman | Administrator | Facility Administrator not present sufficient hours |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 92
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff left a resident soiled for an extended period of time.
Complaint Details
The complaint alleged that staff left a resident soiled for an extended period. The investigation was unannounced and conducted by Licensing Program Analyst Christopher Arnhold. Based on interviews and records, the allegation was unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence to support the allegation that a resident was left soiled for an extended period. Interviews and record reviews indicated the resident was assisted multiple times during the night, and the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 92
Census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Milich | Administrator | Facility administrator named in report header |
| Teresa Oliveri | Executive Nurse | Met with Licensing Program Analyst during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 92
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
An unannounced investigation was conducted in response to a complaint alleging that staff did not keep residents' authorized persons informed about the resident's care.
Complaint Details
The complaint was unsubstantiated based on the investigation findings.
Findings
The investigation found that residents were tested for COVID on 2022-12-16 and responsible parties were notified accordingly. Although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred, and therefore the allegation was unsubstantiated.
Report Facts
Capacity: 92
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Ken Nunes | Executive Director | Met with Licensing Program Analyst during investigation |
| Jessica Milich | Administrator | Named as facility administrator |
| Bethany Moellers | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 92
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility failed to meet residents' care needs.
Complaint Details
The complaint was unsubstantiated after investigation. The allegation was that the facility failed to meet residents' care needs, but evidence did not prove violations occurred.
Findings
The investigation found that the facility met the needs of residents in care. Although incidents of a resident causing self-harm occurred, the facility followed physician orders and emergency protocols. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 92
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Ken Nunes | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 82
Capacity: 92
Deficiencies: 0
Date: Oct 7, 2022
Visit Reason
An unannounced annual required infection control inspection was conducted to evaluate the infection control procedures and practices of the facility.
Findings
The facility was found to be clean, with all exits free from obstruction, properly charged fire extinguishers, secure medications, and adequate PPE supplies. No deficiencies or citations were found during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Milich | Administrator | Met with Licensing Program Analyst during the inspection. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the annual infection control inspection. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 92
Deficiencies: 0
Date: Aug 5, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff did not provide timely assistance to residents, did not follow the food menu, and did not provide adequate food service, as well as an allegation that staff were not CPR trained to assist residents from choking.
Complaint Details
The complaint was investigated and found to be unsubstantiated, meaning the allegations were false, could not have happened, or lacked reasonable basis.
Findings
The investigation found that staff did provide timely assistance to residents, the meal options were consistent with recommended dietary allowances, and the facility always had at least one staff person on duty with CPR and first aid training. The allegations were determined to be unsubstantiated with no citations issued.
Report Facts
Capacity: 92
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Milich | Executive Director | Met with Licensing Program Analyst during investigation |
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 92
Deficiencies: 0
Date: May 25, 2022
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report submitted regarding a resident's skin tear and subsequent medical treatment.
Complaint Details
The visit was triggered by a complaint/incident report about a resident who sustained a skin tear on 04/20/2022, had redness and swelling observed on 04/29/2022, was hospitalized on 05/03/2022, and returned to the facility on 05/09/2022. The facility's handling of the incident was reviewed and found compliant.
Findings
The facility followed all required reporting procedures related to the incident, including notifying involved parties. No citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Milich | Executive Director | Met with Licensing Program Analyst during the visit and involved in review of incident. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 1
Date: Mar 1, 2022
Visit Reason
Unannounced case management visit conducted in response to incident reports submitted to Community Care Licensing regarding medication errors and resident aggression incidents.
Complaint Details
Visit was complaint-related due to incident reports involving medication errors and resident aggression. Substantiation status is not explicitly stated.
Findings
The inspection found that a medication technician administered medication intended for a different resident, which was immediately noticed and addressed with retraining. Additionally, the facility documented aggressive behavior incidents involving another resident, updated the care plan accordingly, and issued a lawful eviction.
Deficiencies (1)
Facility staff gave resident wrong medications, posing a potential risk to residents in care.
Report Facts
Deficiencies cited: 1
Capacity: 92
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jessica Milich | Executive Director | Met with Licensing Program Analyst during inspection |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 71
Capacity: 92
Deficiencies: 0
Date: Oct 26, 2021
Visit Reason
The inspection was an unannounced Annual Required infection control inspection focusing on the Infection Control procedures and practices of the facility.
Findings
The facility was found to be clean, with all exits free from obstruction, and proper storage of toxins and medications. Fire extinguishers were charged and inspected within the last 12 months. The facility had an approved Covid Mitigation plan and adequate PPE supplies. No deficiencies or citations were found during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Milich | Administrator | Met with Licensing Program Analyst during the inspection. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the Annual Required infection control inspection. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 92
Deficiencies: 0
Date: Jul 12, 2021
Visit Reason
The visit was a case management inspection conducted due to an incident where a resident received medication that was not prescribed to them on 2020-05-27.
Complaint Details
The incident involved a medication error where a resident received medication not prescribed. The staff involved no longer works at the facility. The facility retrained staff and notified the physician. Resident was placed on alert charting for observation. No citations were issued.
Findings
The Licensing Program Analyst met with the Executive Director, reviewed the incident, confirmed staff retraining and physician notification, and found the facility to be following regulations with no citations issued.
Report Facts
Capacity: 92
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanna Frost | Executive Director | Met with Licensing Program Analyst during the case management visit |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit |
| Bethany Moellers | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 0
Date: Dec 14, 2020
Visit Reason
The visit was an unannounced complaint investigation conducted due to an allegation that the facility was refusing to take back residents from the hospital.
Complaint Details
The complaint alleged that the facility was refusing to take back residents from the hospital. The allegation was unsubstantiated based on interviews and evidence gathered during the investigation.
Findings
The investigation found that although the facility had been hesitant in the past to accept residents back from the hospital unless they were at baseline, currently the facility accepts residents back as long as they meet regulatory requirements. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Jeanna Frost | Executive Director | Interviewed during the complaint investigation |
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