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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102866
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:12:14 PM


Document Has Been Signed on 09/20/2024 02:12 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:REDWOODS, THEFACILITY NUMBER:
210102866
ADMINISTRATOR:KYLE RUTH-ISLASFACILITY TYPE:
740
ADDRESS:40 CAMINO ALTOTELEPHONE:
(415) 383-2741
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:150CENSUS: 108DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kyle Ruth-Islas- AdministratorTIME COMPLETED:
02:25 PM
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09/20/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 108 residents in care. Facility approved/cleared for 35 non-ambulatory and hospice waiver for 8.

At approximately 9:50am, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. LPA observed an emergency food supply.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, drawers. LPA observed an area of the facility to be under repair for future memory care use and is inaccessible to residents in care. Facility has scheduled activities for residents in care. Facility has residents with special dietary needs that are noted with resident’s names and their needs in the kitchen. Water temperature in sinks accessible to residents in care were measured at 119.4 and 118.4 degrees, within the range of 105 to 120 degrees F. Fire extinguishers were last inspected January, 2024. Smoke detectors, fire sprinklers, and carbon monoxide detectors located throughout the facility were last inspected June 11th, 2024. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

At approximately 11:20 am, LPA conducted review of eight staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

continued on LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: REDWOODS, THE
FACILITY NUMBER: 210102866
VISIT DATE: 09/20/2024
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At approximately 12:00 pm, LPA conducted a review of 8 resident records. All records had the required documentation.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610- Emergency Disaster Plan
LIC9020- Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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