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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102866
Report Date: 07/13/2023
Date Signed: 07/13/2023 09:45:55 AM


Document Has Been Signed on 07/13/2023 09:45 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: 128DATE:
07/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Kyle Ruth-Islas & Jill Ciambriello, Social WorkerTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management- incident inspection regarding a medication error. LPA met with Administrator Kyle Ruth-Islas & Jill Ciambriello, Social Worker.

LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 07/6/2023 of a medication error. The error occurred on 7/5/2023 at the nurse’s station. Resident (R1) came to station for medication, while R2 came into the office with Med Tech. Med Tech handed the agency nurse on duty medication for resident R2 and the nurse mistakenly gave it to R1. (See LIC809-D). All appropriate parties and prescribing physician were notified of the medication error. R1 was sent to hospital overnight for observation. LPA obtained copies of the in-house incident report indicating a medication error along with the Medication Assessment Record (MAR) for the month of July 2023 for R1 that reflects the said medication error.

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: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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 07/13/2023 09:45 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: 07/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
87465(a)(5):

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87465(a)(5): Incidental Medical and Dental Care Services. The facility shall assist residents with self-administered medications when needed.
This requirement is not met as evidenced by:
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Facility has provided proof of Medication Inservice Training with staff names and signatures on it. Facility to also perform random audits on medication administration for 4 weeks to ensure compliance.
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Based off self-reported incident report and interview with Administrator and MSW, the Nurse provided R1, R2’s medication. The facility failed to ensure R1's medication was given as prescribed by doctor which poses an immediate health and safety risk to resident in care.
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Deficiency has been cleared during today’s visit.

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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: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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