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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200305
Report Date: 12/05/2024
Date Signed: 12/05/2024 01:34:44 PM

Document Has Been Signed on 12/05/2024 01:34 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:REDWOOD HOME AT NILES GROVEFACILITY NUMBER:
019200305
ADMINISTRATOR/
DIRECTOR:		EDITH SARMIENTOFACILITY TYPE:
735
ADDRESS:35537 NILES BLVDTELEPHONE:
(510) 818-0720
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 6DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Edith Sarmiento, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 12/05/2024 at 11:15 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Edith Sarmiento, and explained the purpose of the visit. Administrator certificate is current and administrator number is 6002437740. Administrator certificate expires on 07/07/2025. The facility’s fire clearance was approved for all six (6) non-ambulatory and one (1) may be bedridden.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six total bedrooms which all bedrooms are occupied by the clients and one office for the Administrator. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 126.5 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's and linen was available for clients. Cabinet for knives, cleaning supplies, and centrally storage for medication were observed locked. Outdoor activity space was observed furnished with tables, chairs and shade.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/26/2024. First aid kit was observed to be complete. Emergency Disaster Drill was last posted on 03/24/2024. Emergency Disaster Drill was last conducted on 10/02/2024. Fire Drill was last conducted on 09/11/2024.

Continue to LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: REDWOOD HOME AT NILES GROVE
FACILITY NUMBER: 019200305
VISIT DATE: 12/05/2024
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At 11:21 AM, 6 of clients records were reviewed. At 11:50 am, 3 staff records were reviewed and 3 of 3 have current first aid training and 3 of 3 associated to the facility. LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed samples of client's medications. All records were observed to be complete and up to date.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/12/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan
Liability Insurance

THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT:

At 12:10 PM, LPAs observed the water temperature at 126.5 F at the shared bathroom.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/05/2024 01:34 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/05/2024 at 01:02 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: 12/05/2024

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 in having hot water temperature at 126.5 degrees Fahrenheit which poses an immediate health and safety rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Administrator agreed to adjust water temperature to 105 - 120 degrees Fahrenheit and submit photo to CCLD by POC date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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