210102866-8-7-2023-21-AS-SHAN-CUGUB8-20230807152555

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102866
Report Date: 08/07/2023
Date Signed: 08/07/2023 03:26:06 PM

Document Has Been Signed on 08/07/2023 03:26 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	REDWOODS, THE		FACILITY NUMBER:	210102866
ADMINISTRATOR:	KYLE RUTH-ISLAS		FACILITY TYPE:	740
ADDRESS:	40 CAMINO ALTO		TELEPHONE:	(415) 383-2741
CITY:	MILL VALLEY	STATE: CA	ZIP CODE:	94941
CAPACITY:	150	CENSUS: 124	DATE:	08/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kyle Ruth-Islas, Administrator		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1 – year inspection visit of the facility. LPA was welcomed by CEO Hunter Moore, COO/Administrator Kyle Ruth-Islas arrived shortly after. There is a total of 124 residents, 9 of which have dementia diagnosis. There are 3 residents currently on Hospice. LPA toured the facility on 8/7/2023 at 8:45 AM with Administrator Kyle Ruth-Islas; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on 1/11/2023 at the time of the visit. Facility hallway smoke detectors are hard wired and sound directly to the fire station. Smoke detectors, carbon monoxide, and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 4/6/2023. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 113.7 degrees F and 135.5 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 5 of 7 resident’s faucet bathrooms while touring facility on 8/7/2023 at 9:45 AM (see LIC809D). Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area on 8/7/2023 at 9:00 AM with Administrator Kyle Ruth-Islas and learned that there are provisions made for individuals/residents with special dietary needs. Facility kitchen has resident’s names and their needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. (Continue LIC 809-C)

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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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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
	VISIT DATE: 08/07/2023

NARRATIVE

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Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample of eight resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. LPA is advising facility to ensure that beds are outfitted with mattress pads as required by Title 22 Regulations.

A sample review of five resident & seven staff records was conducted. LPA reviewed resident’s files at 12:00 PM on 8/7/2023 and learned that 5 out of 5 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time as required by Title 22 Regulation. Medications were centrally stored in a locked medication cart in the facility medication room.

LPA conducted a sample reviewed of staff records at 1:15 PM on 8/7/2023 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1^st Aid certification for all staff.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information other than email. Disaster Drills are conducted quarterly with the last one being conducted on 7/12//2023. Facility has just finished installation of full cite emergency generator. Kyle Ruth-Islas Administrator Certificate # 6029464740 expires on 1/15/2024.

Appeal of Rights Given.

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.

(Continue LIC 809-C)

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/07/2023 03:26 PM - 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: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance & Operation. Hot water provided for the use of resident sshall be maintained between 105 and 120 degrees F. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the facility failed to have hot water temperature between 105 & 120 degrees F in 5 of 7 resident's bathroom faucets which poses an immediate Health and Safety risk for residents in care. LPA observed hot water temperature between 113.7 & 135.5. degrees F.
	POC Due Date: 08/08/2023
	Plan of Correction
1 2 3 4	Facility to ensure hot wate rtemperature is maintainted within regulation - 105 to 120 F. Facility to submit a LIC 9098 self certification that hot water has been adjusted to be within regulation by POC date 8/8/2023 & begin monitoring for the next 7 days. Administrator to submit a 7 day log taken from the residnet's bathrooms to CCL by 8/16/2023. ***Faility adjusted hot water during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: REDWOODS, THE	FACILITY NUMBER: 210102866
	VISIT DATE: 08/07/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 9/1/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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