496803958-1-27-2021-21-AS-MCUA-BXNNM8-20210127093440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803958
Report Date: 01/26/2021
Date Signed: 01/27/2021 09:34:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	REDWOOD SANTA ROSA		FACILITY NUMBER:	496803958
ADMINISTRATOR:	CARDENAS, CRISANTE		FACILITY TYPE:	740
ADDRESS:	1727 BURBANK AVE		TELEPHONE:	(415) 810-0145
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY:	22	CENSUS: 12	DATE:	01/26/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Anthony Barbato (Applicant)		TIME COMPLETED:	02:30 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) Cuadra conducted an unannounced Pre-licensing Inspection via video conferencing due to Covid-19 precautions with Applicant, Anthony Barbato and Administrator, Crisante Cardenas. Applicant has applied for a Change of Ownership for this already existing facility. There are currently 12 residents in care, no residents receiving hospice services and residents in care with a dementia diagnosis. Facility was approved hospice waiver for five residents on 1/22/2021. The facility is a single-story residence with twelve bedrooms which room 3 and #4 are single occupant, four bathrooms, Administrator’s office, Kitchen area, dining room area, living room, laundry room and waiting room area. There is a separate living unit for live-in staff located outside of the property. Facility received an approved fire clearance January 14, 2021 that allows all bedrooms for non-ambulatory residents. There is no delayed egress/secured perimeter/secure locked perimeter permitted. Applicant conducted a walk through via video conference and LPA observed that resident rooms were furnished per regulations and bathrooms were equipped with nonskid mats and grab bars for safety. All facility bedrooms have all personal accommodations. Each bed has a mattress pad. All bedrooms have adequate lighting, closet and dresser space. LPA observed required postings (LTCO, CCL Complaint poster, visitor policy, employee rights and personal rights). in addition to COVID-19 required visitation postings. Facility has a sanitation station set up at the entrance to the facility in order to comply with Covid-19 precautions. Facility are screening staff or essential visitors for symptoms. The facility staff was observed wearing mask during the virtual tour of main entrance, doors, common areas, dining rooms and kitchen area. Facility provides assistance with family communication via telephone or video call. Facility has adequate dishes and cooking materials to provide meals to residents. Facility has at least two days of perishable and one week of nonperishable foods. Food supplies are maintained in the food storage room located outside of the property. Applicant showed LPA the contents of their First Aid Kit. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: REDWOOD SANTA ROSA	FACILITY NUMBER: 496803958
	VISIT DATE: 01/26/2021

NARRATIVE

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Continued from LIC809...

Facility has space indoors and outdoors for resident activities. Cabinet containing cleaning supplies and kitchen drawer containing other items that could pose a risk were locked. Applicant tested water, reading at 4 bathrooms were 129.6, 127.9, 124.3 and 121.5 Fahrenheit degrees which is not within allowable range, Deficiency observed by LPA and cited on current license # 496803950. Fire extinguisher was last inspected August 2020.

Facility has hardwired combination smoke/ carbon monoxide detectors that were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Resident and staff records are maintained. LPA confirmed with Applicant that if current residents choose to stay after Change of Ownership, a new Admission Agreement will need to be completed. Applicant understood. Medication is centrally stored and locked in a closet. A Centrally Stored Medication Log is maintained. LPA discussed facility's Disaster Preparedness with Applicant including observing their Emergency supplies. Component III Orientation was completed with Administrator. Administrator Certificate # 6025751740 expires 3/24/2021. Pre-licensing passed and COMP III completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation.

LPA will submit copy of the facility report to the Centralized Application Unit and inform of citations. LPA to conduct subsequent pre-licensing inspection after POC's are cleared.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

LIC809 (FAS) - (06/04)

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