Community Care Licensing

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/05/2023 02:58 PM - It Cannot Be Edited

FACILITY NAME: REDWOOD RETREAT	FACILITY NUMBER: 496803402
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	***Based on observation the facility did not have hot water temperature between 105 & 120 F in 1 of 4 resident's bathroom faucets which poses an immediate Health, Safety risk for residents in care. LPA observed hot water temperature in 1 bathroom faucet at 122 degrees F.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Facility to ensure hot water temperature is maintained within regulation - 105 TO 120 F. Facility to submit a LIC 9098 self certification that hot water has been adjusted to be within regulation by POC date of 9/6/2023 & begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 9/13/2023.

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation disinfectant & cleaning solutions under unlocked kitchen sing & 3 paint cans under residents bathroom sink in unlocked cabinet, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that toxins, disinfectants & other items that constitute danger to residents are inaccessible at all time.Administrator removed paint and stored in locked shed in back of facility and agrees to keep kitchen cleaning solutions locked & maintain toxins locked at all times. Licensee to submit LIC 9098 self certification that all items that constitute danger to residents are locked and will be locked at all times to CCL by POC date of 9/6/2023.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/05/2023 02:58 PM - It Cannot Be Edited

FACILITY NAME: REDWOOD RETREAT	FACILITY NUMBER: 496803402
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview & record review, the licensee did not comply with the section cited above in 3 out of 5 staff TB tests were not performed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2023
	Plan of Correction
1 2 3 4	Administrator to submit a copy of the TB test with the results with the Proof of Corrections form by POC due date 9/20/2023 to clear citation.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/05/2023 02:58 PM - It Cannot Be Edited

FACILITY NAME: REDWOOD RETREAT	FACILITY NUMBER: 496803402
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 5 residents (R1) did not have a current medical assessment on file which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee agrees to provide evidence of current assesssment to CCL by POC Due date 9/22/2023

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 5 residents (R1) did not have a signed reappraisal within 12 months which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee will submit Reappraisal signed by responsible party to CCL by POC due date 9/22/2023

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/05/2023 02:58 PM - It Cannot Be Edited

FACILITY NAME: REDWOOD RETREAT	FACILITY NUMBER: 496803402
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview & record review, the licensee did not comply with the section cited above in 1 (R1)out of 2 residents medication review of did not record dosages of medications given which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that all residents' medications are entered on a Centrally Stored Medication Record. Facility to provide CCL with copies of CSMR for all residents' medications by POC date of 9/13/2023. .

Type B

Section Cited

CCR

87411(c)(1)

87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and record review, two out of five staff lacked required first aid certification, the licensee did not comply with the section cited above in two out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 9/13/2023.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

FACILITY NAME: REDWOOD RETREAT	FACILITY NUMBER: 496803402
	VISIT DATE: 09/05/2023

FACILITY NAME: REDWOOD RETREAT	FACILITY NUMBER: 496803402
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation by LPA and staff (see pic) medications for destruction were in unlocked closet next to front door. The medication shoud be centrally stored as required by regulations. This is a health & safety risk and/or a personal rights risk to residents in care.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Administrator to submit documentation they understand regulation by POC due date of 9/6/2023 & then documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance. POC due date 9/8/2023 to Community Care Licensing to clear the citation.

Type A

Section Cited

CCR

87465(i)

87465(i) Incidental Medical and Dental Care (i) Prescription medications which are not taken.. upon termination of services..are otherwise to be disposed of shall be destroyed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation that the facility did not destroy 3 residents medications. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Administrator to ensure that facility is following required destruction procedures at all times. Items must be immediately destroyed according to Title 22 procedures. Administrator to sign self-certification that they have reviewed regulation 87456 Incidental Medical and Dental Care. Administrator agrees to send LPA Hansen self certification by 9/6/2023.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023