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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 181300554
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:45:22 PM

Document Has Been Signed on 12/03/2024 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:REDWINE FAMILY HOMEFACILITY NUMBER:
181300554
ADMINISTRATOR/
DIRECTOR:		LINDEMAN, CARRIEFACILITY TYPE:
735
ADDRESS:461-905 REDWINE LANETELEPHONE:
(530) 253-3287
CITY:JANESVILLESTATE: CAZIP CODE:
96114
CAPACITY: 6CENSUS: 2DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator, Carrie LindemanTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On December 3, 2024 at approximately 10:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Redwine Family Home for the purpose of conducting a Required 1 year inspection. Upon arrival, LPA was greeted at the door by Administrator, Carrie Lindeman and was granted access into the facility. Clients were at their respective Day Programs.

LPA and the Administrator toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. Activity rooms were inspected and found to appropriate during the inspection. Fire Extinguisher was observed to be last inspected on September 2024. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the inspection. Hot water temperature measured at 108 degrees in 1 of 1 clients bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. LPA observed sufficient perishable and non-perishable foods located in the fridge. Food menu was observed and found to be appropriate during the inspection. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Client records, personnel records, medication were locked in separate cabinets, toxins are kept locked and inaccessible to clients in care. Facility has a first aid kit which was inspected and found to be appropriate during the inspection. There is an outdoor space for activities with a shaded area. During the Required 1 year inspection, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 + or any infectious diseases in the facility. Emergency Disaster Plan is currently in the process of being updated (See LIC 9102-Technical Violation). Emergency Disaster Drill was last conducted in December 2024. Infection Control Plan was reviewed and found to be appropriate.

During the Required 1 year inspection, LPAs reviewed 2 of 2 staff files and found those files to be appropriate during the inspection. LPA reviewed 2 of 2 client files. (Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REDWINE FAMILY HOME
FACILITY NUMBER: 181300554
VISIT DATE: 12/03/2024
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 During the inspection, LPA could not locate a LIC 602/Physicians Assessment Report for both clients in care (See LIC 9102-Technical Violation). LPA educated the Administrator on the importance of ensuring that there is a LIC 602/Physicians Assessment Report retained in client files. Administrator will follow-up with the clients respective physicians. 2 of 2 client medication orders were reviewed and found to be appropriate during the inspection.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
Most up-to-date Liability insurance
Updated Surety Bond
Control of Property
Register of clients
Emergency Disaster Plan

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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