<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880705
Report Date: 05/24/2023
Date Signed: 05/24/2023 01:25:13 PM

Document Has Been Signed on 05/24/2023 01:25 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIGNITY LIVING REDWOOD HOMEFACILITY NUMBER:
331880705
ADMINISTRATOR:MARBY, RENEEFACILITY TYPE:
735
ADDRESS:971 REDWOOD CTTELEPHONE:
(951) 427-5508
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 4CENSUS: 4DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Manager- Diane JohnsonTIME COMPLETED:
01:35 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
Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA was greeted and granted entry by the Direct Support Person Stephanie Lopez. LPA later met with Facility Manager (FM) Diane Johnson.
LPA toured the facility inside and out. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/20/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. LPA toured the client bathrooms. The hot water temperature measured within the required limits at 114 degrees Fahrenheit. The outside of the facility lacked a shaded area for clients in care. FM stated the umbrella had broken due to the wind storm, and facility will purchase a new one. Technical violation was issued. The facility does not have bodies of water.
LPA observed the required policies, postings and signs. LPA noted the emergency and disaster plan had not been updated since 2020. Technical Violation issued. LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. LPA reviewed the Administrators file. LPA discovered HIV/TB training had not been filed and/or completed. Technical Violation issued. Client files were reviewed and had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA requested to view the Infection Control plan. FM provided an Infection Control plan for Monkeypox. LPA provided steps to access form: LIC 9282 on the CCLD website. FM proceeded to print out the document for the licensee to complete. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIGNITY LIVING REDWOOD HOME
FACILITY NUMBER: 331880705
VISIT DATE: 05/24/2023
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
Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.

No deficiencies were issued. Three (3) technical violations issued. An exit interview was conducted where this report, LIC 809, LIC 9102, and appeal rights was discussed and provided to the Facility Manager Diane Johnson, at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5