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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 181300554
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:39:11 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/08/2023 12:39 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:LINDEMAN, CARRIEFACILITY TYPE:
735
ADDRESS:461-905 REDWINE LANETELEPHONE:
(530) 253-3287
CITY:JANESVILLESTATE: CAZIP CODE:
96114
CAPACITY: 6CENSUS: 2DATE:
11/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carrie Lindeman AdministratorTIME COMPLETED:
12:50 PM
NARRATIVE
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On 11-08-23 Licensing Program Analyst LPA Sarah Benson met with Administrator Carrie Lindeman to complete a continuation of yearly annual started 11-07-23.

During the visit of 11-07-23 there was clutter in all areas of the house and yard, except the clients rooms. In all areas inspected in the house, dust and dirt was observed on surface areas. On 11-08-23 the clutter was less and dust was removed.

Administrator certificate submitted in 2-2023 and is pending renewal. All required postings are displayed within facility.

The facility has a swimming pool in a out building on the property with a locked door.

LPA found all required document upon reviewing both clients files.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.



Exit interview conducted, a copy of the report, and appeal rights provided to Administrator Carrie Lindeman.


SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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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Document Has Been Signed on 11/08/2023 12:39 PM - It Cannot Be Edited


Created By: Sarah Benson On 11/08/2023 at 11:46 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REDWINE FAMILY HOME
FACILITY NUMBER: 181300554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2023
Section Cited
CCR
80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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The administrator cleaned dust and clutter during LPA's visits.
The corrections were completed 11-08-23.
The administrator will put items into storage.
Dusting and cleaning will be done every 3 days.
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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:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023


LIC809 (FAS) - (06/04)
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