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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600897
Report Date: 07/01/2022
Date Signed: 07/01/2022 10:20:04 AM

Document Has Been Signed on 07/01/2022 10:20 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:REDWOOD ACRES RESIDENTIAL HOMEFACILITY NUMBER:
415600897
ADMINISTRATOR:SARMIENTO, ANNA MARISSA V.FACILITY TYPE:
740
ADDRESS:1728 REDWOOD AVENUETELEPHONE:
(650) 361-1014
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6CENSUS: DATE:
07/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Anna SarmientoTIME COMPLETED:
10:15 AM
NARRATIVE
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On July 1, 2022 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management deficiency visit as a result of complaint closure investigation. LPA met with caregiver Carlos Ordonez and explained the purpose of this case management visit. Around 10am LPA met with licensee Anna Sarmiento and Enrico Victoriano.

It was found during a complaint investigation 3/24/2022 that a staff person (S1) is not associated to the facility showing employment was discontinued on 12/24/2021. Another staff person (S2) is not fingerprint cleared and associated to the facility. LPA reviewed the staff roster with the licensee and confirmed that both caregivers are not associated to the facility at this time.

This violation results in a civil penalty of $100 per person. $100 x 2 staff = $200


Report is reviewed with Enrico Vicoriano. Appeal rights provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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 12/08/2022 10:53 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/23/2022 09:34 AM


Created By: Jaime Vado On 07/01/2022 at 09:44 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: REDWOOD ACRES RESIDENTIAL HOME
FACILITY NUMBER: 415600897

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2022
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Administrator shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 and S2 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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This requirement was not met as evidenced by: Based on records review, licensee failed to request a transfer of criminal record clearance for S1 and S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 and S2 are not associated to the facility on this day 7/1/2022.
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Immediate civil penalty of $100 for S1 and $100 for S2 is being assessed on this day.
Type A
07/02/2022
Section Cited
CCR87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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Administrator shall ensure to submit proof of fingerprinting of S2 and proof of clearance to the licensing office for S2 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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This requirement was not met as evidenced by: Based on records review, licensee failed to obtain a criminal record clearance for S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S2 does not have a criminal record clearance on this day 7/1/2022.
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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:Jackie Jin
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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