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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803402
Report Date: 09/29/2025
Date Signed: 09/29/2025 03:13:33 PM

Document Has Been Signed on 09/29/2025 03:13 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 RETREATFACILITY NUMBER:
496803402
ADMINISTRATOR/
DIRECTOR:		MOESSING, ERICFACILITY TYPE:
740
ADDRESS:4988 OLD REDWOOD HIGHWAYTELEPHONE:
(707) 576-1119
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 15CENSUS: 13DATE:
09/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Eric Moessing, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Inspection of facility and was welcomed by Janette (caregiver), Administrator, Eric Moessing was contacted by staff and arrived during inspection. Facility is a single story RCFE with 13 bedrooms and a fire clearance for 15 Non ambulatory of which 2 may be bedridden. Facility granted hospice waiver for 6. There is currently a total of 13 residents, 6 of which have dementia diagnosis, with 1 resident currently under Hospice care.

On 9/29/2025 at approximately 9:30 AM LPA initiated a tour of the facility with staff and made the following observations: Facility was a comfortable temperature and all exits were 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 108.3 degrees F and 116.2 degrees F within Title 22 acceptable range of 105 to 120 degrees F in 7 out of 7 resident’s bathroom faucets. Extra hygiene products and linens were available. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. 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, overflow of medications are stored in 2 locked cabinets in family room.

Fire extinguisher was last inspected 10/11/2024. Facility has sprinkler system and hard-wired smoke alarm system that is maintained by vendor, last service was conducted 7/14/2025. Combination Smoke alarm and Carbon Monoxide detectors tested and found to be working. Auditory alarms were functional at the time of visit.
Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/29/2025
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Continue from LIC809

File review was initiated at 11:00 am. Five staff files and five resident files along with 2 resident medication records were reviewed. Five resident records were reviewed finding all but 1 resident have current needs and service plans updated (see LIC9102 TA) and all residents have Physicians Assessments per regulations.

At approximately 12:20PM staff records were reviewed. All staff requiring background checks have been cleared and associated to facility. All staff have required training and other required documents. All staff have required First Aid and CPR certificates.

At approximately 1:20 PM Medications of 2 out of 2 residents were found to be given according to physician’s directions. Centrally Stored Medication Records (CSMR) were found to be complete and accurate on 9/29/2025.

Disaster Drills are conducted quarterly and different shifts, with the last one being conducted on 9/16/2025. Administrator Certificates for Eric Moessing, 7005070740, expires 8/16/2026.


No citations given during today’s inspection.




LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/17/2025:

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
Copy of Certificate of Liability Insurance
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC809 (FAS) - (06/04)
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