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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201905
Report Date: 08/15/2024
Date Signed: 08/22/2024 01:53:10 PM

Document Has Been Signed on 08/22/2024 01:53 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:REDWOOD CARE HOMEFACILITY NUMBER:
415201905
ADMINISTRATOR/
DIRECTOR:		DEE-HOSKINS, CRISTINAFACILITY TYPE:
740
ADDRESS:188 DUANE STREETTELEPHONE:
(650) 364-3499
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 18CENSUS: 11DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:26 PM
MET WITH: Christina Dee-Hoskins, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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 **This report was Amended to clarify deficiencies and remove one deficiency.**

On August 15, 2024, Licensing Program Analysts(LPAs) John Calandra and Kiran Jain arrived at the facility at 1:25 PM to complete the Annual 1-year required inspection. LPAs Calandra and Jain were greeted by Lany Becker, Caregiver and explained the purpose of the visit. Christina Dee-Hoskins, Administrator/Licensee joined the visit later.

LPAs Calandra and Jain toured the physical plant. This is a 10 bedroom and 4 bathroom, multistory building with a front and backyard, living room, kitchen, staff quarters, and garage. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed. The facility's fire extinguishers were observed to be fully charged and last checked on 3/14/2024. The facility's fire alarms and carbon monoxide detector were observed to be in working order. The fire alarm system was last inspected on 7/14/2022 and expires on 7/14/2027.

A Type A Violation was provided for having a faucet that delivers hot water temperature measured at 135.7 degrees Fahrenheit far above the required range of 105-120 degrees Fahrenheit.

A Type A Violation was provided for not ensuring that soap and disinfectants are not locked up and in-accessible to persons in care.

A Type A Violation was provided for having medications left out on the kitchen counter that were unlocked and accessible to persons in care.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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
Document Has Been Signed on 08/22/2024 05:02 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/21/2024 04:22 PM


Created By: John Calandra On 08/15/2024 at 02:55 PM
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: REDWOOD CARE HOME
FACILITY NUMBER: 415201905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87303(e)(2): Maintenance and Operations: Based on observation, the licensee did not comply with the section cited above in 1 out of 1 faucets which was delivering water temperature of 135.7 degrees fahrenheit which is above the required range of 105-120 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87309(a): Storage Space: Based on observation, the licensee did not comply with the section cited above in 4 out of 4 soap and detergent bottles which were left out in the kitchen below the sink, where they were accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/22/2024 05:03 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/21/2024 02:03 PM


Created By: John Calandra On 08/15/2024 at 02:55 PM
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: REDWOOD CARE HOME
FACILITY NUMBER: 415201905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87309(b): Storage Space: Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bottles of Vitamin D3 and Glucose tablets that were left on the kitchen counter, where residents might be able to reach them, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Section Cited
General Food Service Requirements
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/22/2024 05:03 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/21/2024 04:38 PM


Created By: John Calandra On 08/15/2024 at 02:55 PM
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: REDWOOD CARE HOME
FACILITY NUMBER: 415201905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87303(a) Maintenance and Operations: Based on observation, the licensee did not comply with the section cited above in 1 out of 1 gates in the backyard which did not open easily as the latch was broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Type B
Section Cited
CCR
87303(i)(1)(B)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 call buttons which did not call for help when pressed or pulled, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: REDWOOD CARE HOME
FACILITY NUMBER: 415201905
VISIT DATE: 08/15/2024
NARRATIVE
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A Type B Violation was provided for having a gate in the backyard that was not in good condition and could not be opened easily.

A Type B Violation was provided for not having a call button system in place that is functioning.

A Technical Violation was provided for not having thermometers in the facility's refrigerators and freezers.

In the presence of the LPAs, the facility's License was moved from it's location in the office to a public place.

LPAs Calandra and Jain requested and received the following documents:

-Current Liability Insurance

The Annual Inspection will be completed at a later date.

Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted. This report was reviewed with Christina Dee-Hoskins and a copy of the report along with Appeal rights left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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