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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803958
Report Date: 08/05/2021
Date Signed: 08/05/2021 11:01:42 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 ROSAFACILITY NUMBER:
496803958
ADMINISTRATOR:CARDENAS, CRISANTEFACILITY TYPE:
740
ADDRESS:1727 BURBANK AVETELEPHONE:
(707) 542-1940
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:26CENSUS: DATE:
08/05/2021
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Anthony Barbato (Licensee)TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived announced and met with Licensee, Anthony Barbato to conduct a case management visit to cite other deficiencies discovered during a complaint investigation.

Facility failed to follow their Emergency Plan. Staff did not ensure resident’s medication was moved to the hotel with them after the “Order to Vacate” was issued by the City of Santa Rosa. LPA also learned while staff prepared residents to relocate residents did not have their personal belongings moved with them. On June 10, 2021 LPA learned resident (R1), did not have their personal belongings including R1’s hearing aid and incontinence care supplies brought to the relocation site. On June 14, 2021, Licensee notified LPA that he personally dropped off personal belongings to R1’s responsible party. Additionally, resident (R7) was relocated to another licensed facility, but staff did not ensure their personal belongings were available upon arrival. Based on confidential interviews with staff and families, R7’s personal belongings were not provided to the relocation site until on the weekend of July 4, 2021.

After a review of records, LPA learned that 13 of 13 residents did not sign new admission agreements after Redwood Santa Rosa was licensed. Several areas of the old Admission Agreement for the previous licensee did not apply and new agreements were reviewed by the Central Applications Bureau during the application process. Per the pre-licensing report dated January 26, 2021, “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.” Licensee failed to have existing residents fill out the new Admission Agreements.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2021
Section Cited

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Type A – §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights:(5) To be accorded safe, healthful, & comfortable accommodations...(6) To care... & services that meet their individual needs & are delivered by staff that are...competency to meet their needs. This requirement has not been met as evidence by:
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Based on records review, observations and interviews conducted Licensee did not ensure services individual care needs were met for 2 of 13 residents which poses an immediate risk to the health and safety of residents in care.
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Type A
08/05/2021
Section Cited

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Type A - 87223 Relocation of Resident (a) When a resident must be relocated…, the licensee shall… cooperate with the Dpt in the relocation process. Such cooperation shall include, but not be limited to, the following activities: (1)...other belongings of the resident. This requirement has not been met as evidence by:
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Based on records review, observations and interviews conducted with Administrator/Licensee did not ensure to relocate medication cart with residents at the time of evacuation to the relocation site which poses an immediate risk to the health and safety of residents in care.

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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) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2021
Section Cited

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Type B - 87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than 7 days following admission. This requirement has not been met as evidence by:
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Based on records review and interviews Administrator/Licensee did not ensure there was a sign new admission agreement upon change of ownership as agreed during Pre-licensing inspection on 1/26/2021 for 13 of 13 residents which poses a potential risk to the health and safety of residents in care.
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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) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3