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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201905
Report Date: 08/18/2022
Date Signed: 08/18/2022 12:58:46 PM

Document Has Been Signed on 08/18/2022 12:58 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:REDWOOD CARE HOMEFACILITY NUMBER:
415201905
ADMINISTRATOR:DEE-HOSKINS, CRISTINAFACILITY TYPE:
740
ADDRESS:188 DUANE STREETTELEPHONE:
(650) 364-3499
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 18CENSUS: 12DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Chad TanTIME COMPLETED:
01:10 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
On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility staff person Chad Tan and let him know the purpose of today's visit. Upon entry LPA observed COVID postings upon entry to the facility on front door. LPA signed in and had temperature taken.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings and hand washing signs are present inside the facility. Hand sanitizer is observed as available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medications are locked and not accessible. LPA observed empty medication containers for residents on a dining table adjacent to kitchen. LPA inspected the containers and they are empty. First aid kit is observed as in place in the kitchen. Toilet and bathing facilities are equipped with grab bars and non-slip mats. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken on lower level common bathrooms at 128F. Laundry machines and dryers are observed as functioning. Emergency food supply, dry goods, and perishables are observed as in place. Fire extinguishers are charged ready for use. Last stamped as inspected on 6/22/22.

Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed but requires more supply to be present. Medications, toxins are stored appropriately and inaccessible to clients. LPA attempted to review first aid cards, resident and staff temperature logs, and staff files but they are not accessible to LPA on this day. Resident temperature logs and staff logs are current. All staff are vaccinated. Clients are fully vaccinated as well according to staff.

A disaster and mass casualty plan is present dated 2019. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been finger print cleared and associated to the facility. Mitigation and Infection control plan is not present for review. Administrator certificate is current expiring 9/8/2023.

LPA is requesting the following updated forms to be sent to the Department by 8/22/22:

• Copy of administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan
• LIC 9020 Client Roster

Report is reviewed with caregiver. Deficiency cited on following 809D.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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 2
Document Has Been Signed on 08/18/2022 12:58 PM - It Cannot Be Edited


Created By: Jaime Vado On 08/18/2022 at 12:29 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: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2022
Section Cited
CCR
80088(e)(1)

1
2
3
4
5
6
7
Furniture, Fixtures, Equipment, and Supplies - Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
1
2
3
4
5
6
7
To ensure compliance with this regulation the licensee shall lower the overall hot water temperature of the faciilty. LPA is to receive evidence of hot water temperature within the range of 105F and 120F. Licensee will make a written plan on how this will be prevented from happening in the future.
8
9
10
11
12
13
14
This regulation has not been met as evidenced by: LPA tested the water temperature in two common bathrooms, one at the rear and one at the front, of the facility. Temp measured at 128F.
8
9
10
11
12
13
14
POC due by 08/19/2022
Type B
08/25/2022
Section Cited
CCR80066(c)

1
2
3
4
5
6
7
Personnel Records - All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.
1
2
3
4
5
6
7
To ensure compliance with this regulation the licensee shall provide LPA with evidence of first aid cards, temperature logs, infection control plan, and mitigation plan. Licensee shall create a plan to have records available on site at all times for licensing review.
8
9
10
11
12
13
14
This regulation has not been met as evidenced by: LPA attempted to review the first aid cards, temperature logs, infection control plan, and mitigation plan of the facility but they were not accessible to staff to provide to LPA.
8
9
10
11
12
13
14
POC due by 08/25/2022
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:Jackie Jin
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2