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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803329
Report Date: 05/04/2022
Date Signed: 05/04/2022 11:29:49 AM

Document Has Been Signed on 05/04/2022 11:29 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:REDWOOD CREEKFACILITY NUMBER:
236803329
ADMINISTRATOR:CARMICHAEL, DOROTHYFACILITY TYPE:
735
ADDRESS:414 SOUTH MAIN STREETTELEPHONE:
(707) 459-6134
CITY:WILLITSSTATE: CAZIP CODE:
95490
CAPACITY: 16CENSUS: 14DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Dorothy CarmichaelTIME COMPLETED:
11:45 AM
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At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an unexpected death of a resident. LPA met with Administrator Dorothy Carmichael. Resident informed staff they were not feeling well, and staff escorted resident to ER to be evaluated on 04/15/2022 and was later admitted. Facility contacted hospital daily for updates, and were told resident was improving. On 04/26/2022, facility was informed by the residents hospital case manager, that resident had passed on 04/24/2022. Facility was told resident passed due to effects of a long term, untreated illness. Facility was not provided a death certificate. LPA requested a copy of certificate when facility receives one.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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