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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102866
Report Date: 06/29/2023
Date Signed: 06/29/2023 10:19:02 AM


Document Has Been Signed on 06/29/2023 10:19 AM - 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, 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: 126DATE:
06/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Kyle Ruth-Islas, Administrator & Jill Ciambriello, Social WorkerTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an investigation into a self reported incident report received by Community Care Licensing (CCL) on 06/21/2023 regarding an incident that occurred on 06/18/2023. LPA met with Kyle Ruth-Islas, Administrator .

Based on incident report of 6/21/2023, resident (R1) left the facility unassisted and after search of facility ground and surrounding areas R1 was found across the street approximately 30 minutes later. No injuries noted. R1 then walked back with staff. R1’s Physician's report dated 1/3/2023 indicates R1 cannot be in the community without assistance from the staff. 24 hr private caregiver has been put in place to monitor. Facility reported to physician, responsible party and Community Care Licensing.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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 06/29/2023 10:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: REDWOODS, THE
FACILITY NUMBER: 210102866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
HSC
1569.312(d)

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1569.312(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. Based on review of incident report and interview with Administrator, this requirement has not been met as evidence by:
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Facility to conduct elopement staff training and provide documentation of completion with staff signatures & dated, due by POC date 6/30/23. Facility & family have implemented 24 hr private caregiver for R1. Facilty having 602 updated today and will provide with Care PLan on POC due date.
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Facility reported that R1 left facility unassisted. LPA gathered statements and documents from Administrator and Social Worker. R1's Physician Report states that R1 cannot leave facility unattended. This is a potential risk to the health and safety of residents in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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