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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201905
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:46:53 PM

Document Has Been Signed on 08/22/2024 03:46 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: 10DATE:
08/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH: Cristina Dee-Hoskins, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On August 22, 2024, at 8:35 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the Annual 1-year required inspection. LPA Calandra was greeted by Cristina Dee-Hoskins, Administrator and explained the purpose of the visit.

LPA Calandra reviewed 5 resident files and 5 staff files. All staff files were observed to be complete. All 5 resident files reviewed were missing the Needs and Services Plan.

The facility does not handle cash resources for residents but has an active surety bond.

A Type B Violation was provided for not having Needs and Services Plans for 5 residents.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

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 Cristina Dee-Hoskins, Administrator/Licensee and a copy of the report along with Appeal rights left at the facility. This report was emailed to the Administrator/Licensee, Cristina Dee-Hoskins.
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)
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Document Has Been Signed on 08/22/2024 03:46 PM - It Cannot Be Edited


Created By: John Calandra On 08/22/2024 at 03:02 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: REDWOOD CARE HOME
FACILITY NUMBER: 415201905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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HSC 1569.695(e)(2): Emergency Plans: Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident files which were missing the Needs and Services Plan or Care Plan, 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. Licensee to submit requested documents (Needs and Services Plans) by the due date.
Section Cited
Other Provisions
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: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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