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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803578
Report Date: 10/21/2022
Date Signed: 10/21/2022 01:11:10 PM

Document Has Been Signed on 10/21/2022 01:11 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:REDWOOD VALLEY HOUSEFACILITY NUMBER:
236803578
ADMINISTRATOR:HIRE, BRANDONFACILITY TYPE:
735
ADDRESS:7501 UVA DRIVETELEPHONE:
(707) 292-1657
CITY:REDWOOD VALLEYSTATE: CAZIP CODE:
95470
CAPACITY: 5CENSUS: 5DATE:
10/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sara JudiceTIME COMPLETED:
01:25 PM
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At approximately 12:00PM, 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 10/20/2022. LPA met with house manager Sara Judice and reviewed records. The incident was in regards to a client spilling a bowl of food and receiving a burn on their arm. LPA interviewed staff regarding the dietary habits of C1. Staff (S1) states that C1 is able to communicate and has stated they enjoy their food hot. C1 is on a finely chopped or puree diet. This incident occurred during the evening meal. While eating, C1 accidentally knocked over the bowl of food and the contents came into contact with their arm, causing a small burn to the inside of their arm. Staff immediately provided first aid. Facility updated their protocol to ensure the temperature of the food is taken before given to C1.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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