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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803329
Report Date: 06/07/2022
Date Signed: 06/07/2022 10:06:05 AM

Document Has Been Signed on 06/07/2022 10:06 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: 15DATE:
06/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dorothy CarmichaelTIME COMPLETED:
10:15 AM
NARRATIVE
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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an incident report submitted to CCL on 05/31/2022. LPA met with Administrator Dorothy Carmichael. The incident involved a staff member, S1, administering medication to a Client, C1 that was prescribed to a different Client, C2. According to the report, the error occurred due to S1 being distracted while assisting with medications. Administrator was notified and changes to the way medication is handled have been implemented. LPA requested additional medication training to be conducted with all staff that assist with medication administration.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator and Appeal rights were given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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Document Has Been Signed on 06/07/2022 10:06 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 06/07/2022 at 09:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: REDWOOD CREEK
FACILITY NUMBER: 236803329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2022
Section Cited
CCR
80075

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80075 Health Related Services:(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on
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Licensee to ensure Clients receive the proper medication as ordered by physician. Licensee to schedule refresher training for all staff that assist with medications by POC date of 06/08/2022. Training to
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records reviewed, Licensee did not ensure client received the correct medication. This poses an immediate Health, Safety or Personal rights risk to Clients in care.
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be completed by 07/01/2022. Training material and staff sign in sheets to be submitted to CCL by 07/01/2022.

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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 Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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