496803402-9-16-2024-21-AS-SHAN-D96TW9-20240916150509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803402
Report Date: 09/16/2024
Date Signed: 09/16/2024 03:56:29 PM

Document Has Been Signed on 09/16/2024 03:56 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:	09/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Eric Moessing, Administrator		TIME COMPLETED:	03:15 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	Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Required Inspection of the facility and was welcomed by Janette (caregiver), Administrator, Eric Moessing was contacted by staff and arrived during inspection. There is a total of 15 residents, 8 of which have dementia diagnosis. There are 2 residents’ currently on Hospice. Facility has clearance for 15 non-ambulatory, 2 of which can be bedridden and a Hospice Waiver Approval for 6. LPA initiated a tour of the facility with staff at 10:20 am and made the following observations: Facility was a comfortable temperature and free from obstructions. Activity calendar observed and menus posted. Required postings were observed. Resident rooms were furnished per regulation. Water temperature in resident's bathroom faucets measured between 111.2 degrees F and 113.5 degrees F within Title 22 acceptable range of 105 to 120 degrees F in 4 out of 4 resident’s bathroom faucets. Extra hygiene products and linens were available. Bathrooms had required bathmats and grab bars. Toxins are in locked cabinet in hallway closet, under kitchen sink & in locked laundry room. Medications are centrally stored in the medication cabinet in the kitchen which was locked at the time of inspection; although LPA observed two containers of medications for med pass on kitchen counter, accessible to residents in care 87465(i)(see pic)(see LIC809-D). Fire extinguisher was last inspected 10/6/2023. Facility has a hard-wired smoke alarm system that is maintained by a vendor. Facility's last service was conducted 7/2024. Carbon Monoxide detectors tested and found to be working. Auditory alarms were functional at the time of visit. File review was initiated at 11:15 am. Five staff files and five resident files along with 2 resident medication records were reviewed. All staff have required First Aid and CPR certificates. One staff (S1) out of five staff do not have required TB test on file (see LIC 809-D). One out of 5 staff (S2) does not have required Health Screening (see LIC-809-D). Continues on LIC 809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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: 09/16/2024

NARRATIVE

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Continued from LIC809

All staff requiring background checks have been cleared and associated to facility. All staff have required training. At approximately 12:15 PM resident records were reviewed finding all residents have current needs and service plans updated and all but 1 resident (R1) has updated Physicians Reports (see LIC 809-D). At approximately 1:20 PM Medications and medication records were reviewed and found to be up to date.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any information. Disaster Drills are conducted quarterly with the last one being conducted on 7/26/2024. Administrator Certificates for Administrator Eric Moessing, 6017309740, expired on 8/16/2024 although LPA observed, proof of pending certificate.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/7/2024:

LIC 308 Designated (if changes)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate (when receive)
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: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2024 03:56 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(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 LPA's & Administrator's interview &record review, the licensee did not comply with the section cited above in 2 out of 5 staff did not either have Health Screening (S2) or TB test results (S1) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Administrator to submit TB test results for S1 and Health Screaning for S2 to CCL by POC due date of 9/27/2024 to clear citation.

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2024 03:56 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2) Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation (see pics), the licensee did not comply with the section cited above in finding medications in 2 containers on kitchen counter accessible to persons other then employees. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Admin to conduct staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Admin to submit date of training to LPA by POC due date of 9/17/2024 &. Administrator to submit documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance. POC due date 10/1/2024 to CCL to clear the citation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2024 03:56 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705(c)(5) Care Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1out of 5 residents (R1) records reviewed having Dementia did not have an annual medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2024
	Plan of Correction
1 2 3 4	Administrator agrees to send in proof of current medical assessment for resident R1 and statement they understand regulation 87705(c)(5) by POC due date of 9/30/2024. Administrator will contact LPA is more time is needed for extension.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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