496803470-12-10-2024-21-AS-DALO-DBTV3W-20241210150525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803470
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:05:30 PM

Document Has Been Signed on 12/10/2024 03:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	REDWOOD VISTA RESIDENTIAL CARE HOME		FACILITY NUMBER:	496803470
ADMINISTRATOR/ DIRECTOR:	ANGELICA MARTINEZ		FACILITY TYPE:	740
ADDRESS:	8052 WHIPPOORWILL COURT		TELEPHONE:	(707) 620-0243
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Angelica Martinez-Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:25 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) Alviso conducted a Required- 1 Year visit, on 12/10/24 at approximately 10:00am, and met with Licensee/Administrator Angelica Martinez. Fire clearance is approved for six (6) non-ambulatory, of which one (1) may be bedridden. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. LPA toured the facility with the Administrator. Hot water was checked at 116. degrees Fahrenheit, which is within regulation. The food supply was sufficient in perishable and non-perishable items. The facility had a sufficient supply of linens, furnishings, paper products, hygiene items, cleaners/disinfectants, and personal protective equipment (PPE) for use by the facility. The exits were free and clear from obstruction. All medications were locked and inaccessible to residents in care. All cleaners/disinfectants were locked and inaccessible to residents in care. Facility has two (2) fire extinguishers that were serviced and tagged as required. The facility had all required smoke alarms, all working appropriately. Facility carbon monoxide detector was working appropriately. All exits had auditory alarms. There are currently five (5) residents in care; Four (4) of the residents were at day program during the inspection. LPA reviewed five resident files, including medication records. LPA reviewed four staff files, including training. All staff have criminal record clearance as required. All staff have first aid and cpr certification as required. Continued on LIC809C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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

FACILITY NAME: REDWOOD VISTA RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803470
	VISIT DATE: 12/10/2024

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 1/10/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review, update as needed/required- submit copy)
Infection Control Plan- (ensure to review, update as needed/required- submit copy)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate

The following deficiencies were observed during the inspection:

Per review of records, there was no documentation showing proof of having conducted required emergency disaster quarterly drills; Administrator was not able to show proof of quarterly drills having been conducted. This deficiency will be cited, HSC 1569.695(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. 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, see LIC809D.

Per record reviews, S1, S2, and S4 lacked CPR certification, and S3 lacked first aid and CPR certifications. Administrator was not able to show proof of staff having the training specified above for each staff. This deficiency will be cited, HSC 1569.618(c)(3) Other Provisions Section – Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and staff have first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR, see LIC809D.

Deficiencies 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 with Licensee/Administrator Angelica Martinez.
Appeal rights given to the Administrator.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/10/2024 03:05 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
SANTA ROSA RO, 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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
1 2 3 4	Per review of records, there was no documentation showing proof of having conducted required emergency disaster quarterly drills; Administrator was not able to show proof of quarterly drills having been conducted, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to submit plan in how the facility will ensure to conduct "quarterly" emergency disaster drills as required. Conduct an emergency disaster drill, and document it as required. Submit the plan, and emergency disaster drill conducted, by POC due date of 12/20/24.

Section Cited

1569.618(c)(3) Other Provisions Section – Other Provisions Section – Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and staff have first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per record reviews, S1, S2, lacked CPR certification, and S3 lacked first aid and CPR certifications. Administrator was not able to show proof of staff having the training listed, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure that staff, S1, S2, S3, and S4, obtain the required First Aid and/or CPR ;isted above as required. Submit proof of trainings having been obtained and completed by POC due date of 12/11/24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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