496803470-11-3-2022-21-AS-VBEI-CKTNHW-20221103102924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803470
Report Date: 11/03/2022
Date Signed: 11/03/2022 10:29:31 AM

Document Has Been Signed on 11/03/2022 10:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	REDWOOD VISTA RESIDENTIAL CARE HOME		FACILITY NUMBER:	496803470
ADMINISTRATOR:	ANGELICA MARTINEZ		FACILITY TYPE:	740
ADDRESS:	8052 WHIPPOORWILL COURT		TELEPHONE:	(707) 620-0243
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	6	CENSUS: 6	DATE:	11/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee Angelica Martinez		TIME COMPLETED:	10:40 AM

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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Licensee, Angelica Martinez. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff for Covid-19. LPA initiated a walk-through of the facility around 9:10am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected twice per day. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) and have been N95 fit tested. Licensee and LPA discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced October 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.

Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: REDWOOD VISTA RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803470
	VISIT DATE: 11/03/2022

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Continued from LIC809C

Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit updates of the following documents by 12/03/2022:
LIC 308 Designated Administrator (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update)
LIC 9020 Register of Facility Residents
Most recent care plan and LIC602 for all residents
Copy of Liability Insurance

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

LIC809 (FAS) - (06/04)

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