496803402-9-13-2022-21-AS-SHAN-CJ8UWM-20220913155658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803402
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:57:06 PM

Document Has Been Signed on 09/13/2022 03:57 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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: 15	DATE:	09/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee Eric Moessing		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by staff who directed LPA to sanitize hands, screen for symptoms, and sign-in on visitor sheet. LPA met with Licensee Eric Moessing. There are 15 residents in care at the facility with 3 on Hospice and 6 with dementia.

Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility began the process today of having new flooring put in the front room and hallways which will be complete tomorrow. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. 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 114.4degrees F to 118.4 degrees F which is 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 inaccessible to residents. Medications are centrally stored and locked in kitchen cabinet.

Fire extinguisher was last inspected 8/18/2021 but is fully charged. Facility's last fire alarm service inspection was conducted 11/2021. Last Disaster Drill was conducted on 7/26/2022. Auditory alarms were functional at the time of visit.

Infection Control:

Facility has submitted a mitigation program plan that has been approved along with Infection Control Plan. Posters have been placed at facility. Entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in spare hallway closet. Facility has a 30-day supply of medication for residents. All staff had masks on during this visit.

Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: REDWOOD RETREAT	FACILITY NUMBER: 496803402
	VISIT DATE: 09/13/2022

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LPA Hansen reviewed Licensing Information System (LIS) with Licensee 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. 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 was presented with proof of current CPR & 1^st Aid certification for staff.

Administrator Certificate is for Eric Moessing #6017309740 Exp. 8/16/2022 – Was renewed 8-9-22 & is pending
All staff have received COVID booster vaccinations.

LPA Hansen is requesting Licensee to update and submit the following documents by 9/27/2022:

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC809 (FAS) - (06/04)

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