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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200305
Report Date: 12/15/2021
Date Signed: 12/15/2021 05:23:11 PM

Document Has Been Signed on 12/15/2021 05:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:REDWOOD HOME AT NILES GROVEFACILITY NUMBER:
019200305
ADMINISTRATOR:EDITH SARMIENTOFACILITY TYPE:
735
ADDRESS:35537 NILES BLVDTELEPHONE:
(510) 818-0720
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 5DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:ADM Edith Sarmiento and ED Chandreve ClayTIME COMPLETED:
05:30 PM
NARRATIVE
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On 12/15/2021 at 1:00PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced and met with Administrator Edith Sarmiento and Executive Director Chandreve Clay. The LPA explained the reason for the visit, which was to conducted an infection control annual inspection.

Accompanied by Ms. Sarmiento and Ms. Clay, the LPA toured the facility inside and out. The facility has a completed COVID-19 mitigation plan (LIC 808) and the LPA observed that staff are following all of the Department and Public Health Covid-19 infection control guidelines, including screening of all visitors and staff, all staff wearing face masks, and Covuid-19 signs at the entry point for visitors and throughout the facility to promote hand washing, cough and sneeze etiquette, physical distancing, and mask wearing.

A high level of care was provided to their clients. The facility is well maintained and there are no obstructions. There were sufficient supplies of food, paper supplies, and PPE. The temperature within the facility was maintained at a comfortable level. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation.

The facility was cited for one deficiency:
  • Type A: hot water temperature measured at 127 degrees F

An exit interview conducted and a copy of this report and Appeal Rights were provided to the ADM.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/15/2021 05:23 PM - It Cannot Be Edited


Created By: James Sampair On 12/15/2021 at 04:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD HOME AT NILES GROVE
FACILITY NUMBER: 019200305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with the hot water temperature at 127 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2021
Plan of Correction
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Reduce hot water temperature to the safe 105 to 120 degrees F and have manager attest to LPA via email by POC due date that the hot water temperature has been reduced to the safe range when measured in a glass after reaching its highest temperature.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021


LIC809 (FAS) - (06/04)
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