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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803470
Report Date: 11/16/2023
Date Signed: 11/16/2023 03:40:34 PM


Document Has Been Signed on 11/16/2023 03:40 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 VISTA RESIDENTIAL CARE HOMEFACILITY NUMBER:
496803470
ADMINISTRATOR:ANGELICA MARTINEZFACILITY TYPE:
740
ADDRESS:8052 WHIPPOORWILL COURTTELEPHONE:
(707) 620-0243
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 6DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Angelica Martinez, Licensee/AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA was welcomed by staff Laura Lopez Monroy. Angelica Martinez - Licensee was contacted by staff and arrived during the visit. There were two caregivers providing care and supervision for 3 residents. Three residents were at day program. There is no residents currently with a diagnostic of dementia, as well no residents on Hospice or using oxygen.

LPA initiated a tour of the facility at 9:00 AM on 11/16/2023 and made the following observations: Facility was found to be clean and at a comfortable temperature with all passageways and exits free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathrooms measured at 118.5 degrees F and 119.1 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 11/16/2023. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet in garage containing cleaning supplies and toxins was unlocked along with cabinet underneath kitchen sink containing cleaning supplies, Regulation 87309(a)(see LIC809-D). Bathroom contained cloth towels and no paper towels for clients use, Regulation 87307(3)(c)(TV see LIC9102). Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored in kitchen cabinet although unlocked, Regulation 87465(h)(2) (see LIC809-D).

Fire extinguisher was last inspected 9/15/2023. Smoke detectors and Carbon Monoxide detectors located throughout facility were tested and operational. All six exit doors have auditory alerts that were functional at time of visit.

Continued on LIC809C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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Document Has Been Signed on 11/16/2023 03:40 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 VISTA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 locations, under unlocked kitchen sink was cleaning solutions & in unlocked cabinet in garage disinfectants & cleaning supplies as bleach, etc which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee will submit a written plan to CCL outlining their protocol to keep items that pose a risk to residents in care inaccessible no later than POC due date, 11/17/2023.
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
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Based on observation by LPA (see pic) medications were in unlocked kitchen cabinet. 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: 11/17/2023
Plan of Correction
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Administrator to submit documentation they understand regulation by POC due date of 11/17/2023 & then documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance.
POC due date 11/21/2023 to Community Care Licensing to clear the 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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2023 03:40 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 VISTA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 LPA observed all residents medications had been prepoured into plastic containers, in both kithen cabinet and outside office (see pics), which were to be given to the residents as stated. Medications are to remain in original containers. This is a potenitial risk to health & safety and/or personal rights risk to residents in care.
POC Due Date: 11/24/2023
Plan of Correction
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 Licensee to submit policy and procedures regarding storage of medications, submit plan of correction by 11/19/23. Facility to ensure that medications are not transferred between containers at any time, per egulation medications are to remain in origianl containers. Licensee to ensure all staff are retrained in medication procedures, submit proof of training by 11/24/23.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews conducted, the licensee informed drills were only conducted every six months and the last one had not been conducted in over a year per records, and did not comply with the section cited above per regulation, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Licensee to submit written plan, outlining how facility will conduct required drills per regulation. Licensee will also conduct a drill and submit written evidence of completed drill to CCL by POC date of 11/24/2023
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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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 VISTA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803470
VISIT DATE: 11/16/2023
NARRATIVE
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Continued from LIC809

A review of 6 resident & 6 staff records as well as two resident’s medications was conducted during this visit. LPA reviewed resident’s files at 10:45 AM on 11/16/2023 and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans, IPP's and updated physician’s assessments (LIC 602A) on file.

The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 11/16/2023 at 1:30 PM; although facility is pre-pouring medications (see pics) in kitchen and outside office, Regulation 87465(h)(5) (see LIC 809D) Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be incomplete and inaccurate per regulations (see TV LIC9102)

LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff files have proof of annual training requirements for 2023 on file. LPA was presented with proof of CPR for required staff although none of the six staff had required 1st Aid certification in files that were reviewed, Regulation 87411(c )(1) (see LIC 809-D). Administrator Certificate for Angelica Martinez 6001706740 expires 4/10/2025.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Administrator informed Disaster Drills are conducted every six months although regulations is quarterly with the last disaster drill being conducted on 1/18/2022, over a year ago out of Title 22 regulations HSC 1569.696(c).

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.

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/16/2023 03:40 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 VISTA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on LPA's record review and interview with Licensee, six out of six staff lacked required first aid certification, the licensee did not comply with the section cited above in 6 out of 6]staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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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 11/30/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8


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 VISTA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803470
VISIT DATE: 11/16/2023
NARRATIVE
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LPA Hansen is requesting facility to submit the following documents to CCL by 12/05/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrators Certificate
Copy of Control of Property Deed
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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