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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803578
Report Date: 06/18/2024
Date Signed: 06/18/2024 11:07:56 AM

Document Has Been Signed on 06/18/2024 11:07 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 VALLEY HOUSEFACILITY NUMBER:
236803578
ADMINISTRATOR/
DIRECTOR:
HIRE, BRANDONFACILITY TYPE:
735
ADDRESS:7501 UVA DRIVETELEPHONE:
(707) 485-1355
CITY:REDWOOD VALLEYSTATE: CAZIP CODE:
95470
CAPACITY: 5CENSUS: 5DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Brandon HireTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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At approximately 09:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Brandon Hire and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. First Aid/CPR certification was current. Medications were reviewed. LPA followed up on an unusual incident report submitted to CCL on 05/10/2024, where staff did not provide medication to 1 of 5 residents. The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility conducts disaster drills monthly.

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: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 06/18/2024 11:07 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 06/18/2024 at 10:50 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 VALLEY HOUSE

FACILITY NUMBER: 236803578

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Staff did not provide medication to 1 of 5 clients on 05/09/2024. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee to ensure clients receive medication as ordered by Physician. Licensee conducted retraining for all staff. POC cleared at time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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