496803402-9-9-2021-21-AS-SHAN-C6PPRW-20210909113326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803402
Report Date: 09/09/2021
Date Signed: 09/09/2021 11:33:35 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	REDWOOD RETREAT		FACILITY NUMBER:	496803402
ADMINISTRATOR:	MOESSING, ERIC		FACILITY TYPE:	740
ADDRESS:	4988 OLD REDWOOD HIGHWAY		TELEPHONE:	(707) 576-1119
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	15	CENSUS: 14	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator/Director Eric Moessing		TIME COMPLETED:	11:33 AM

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	At 9:15 AM on 9/9/2021 Licensing Program Analyst Hansen arrived unannounced to conduct a required Annual 1 yr. Infection Control inspection and was met by Staff Monette Temple who called Administrator to inform of DDS/CCL LPA Hansen. Administrator Eric Moessing arrived approximately 20 minutes later and continued inspection with LPA. Facility has a capacity of 15, at this time census is 14 with a hospice waiver for 6 although only 3 on hospice at this time. LPA arrived at the facility and had temperature checked and logged into visitor’s binder. The facility was a comfortable temperature, free from obstructions and was well lit. There was a sufficient amount of perishable and non-perishable foods in the kitchen and in locked storage room off of the kitchen. Extra hygiene products and linens were available and required bathmats and grab bars were observed. Water temperature in resident's bathrooms measured 116.4 degrees F and 118 degrees F which are within acceptable range of 105 to 120 degrees F. Cleaning products and other toxins are located in locked cabinet under kitchen sink and in locked laundry room. Knives are kept in a locked cabinet in the kitchen. Medications are centrally stored and locked in kitchen cabinet at time of inspection. Fire extinguisher was last inspected August 18, 2021. Facility has a hard wired smoke alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last service was conducted June, 2021. Last Disaster Drill was conducted on 6/2021. Auditory alarms were functional at the time of visit. S1 has required 1st Aid and CPR certificates, with expiration date of 8/1/2021. S2 also has required 1^st Aid and CPR certificates, with expiration date of 3/10/2023 and, S3 has 1^st Aid and CPR certificate with expiration date of 7/10/2023. Continue LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: REDWOOD RETREAT	FACILITY NUMBER: 496803402
	VISIT DATE: 09/09/2021

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

Infection Control:

Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored under laundry room. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility. All staff had masks on during this visit.

LPA Hansen reviewed Licensing Information System (LIS) with Administrator Moessing who stated that it is correct and updated at this time. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

In addition, facility has a designated area for visitors outside and in their own bedrooms with family as well residents have been using Facetime, Zoom, and telephone calls for visits. Facility was conducting group exercises with a facilitator at the time of visit and LPA was informed residence have exercise class every Tue/Thur/Sunday and they play Bingo on Mondays.

Staff had all PPE training required on file and have obtained N-95 fit testing.

LPA Hansen is requesting Licensee to update and submit the following documents by 9/23/2021:

LIC 308 Designated

LIC 309 Administrative Organization

Articles of Corporation

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2