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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570300654
Report Date: 08/02/2021
Date Signed: 08/02/2021 05:57:16 PM

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:ST. JOHN'S RETIREMENT VILLAGE/MANORFACILITY NUMBER:
570300654
ADMINISTRATOR:WHEELER, HEIDI MARIEFACILITY TYPE:
740
ADDRESS:135 WOODLAND AVENUETELEPHONE:
(530) 662-1290
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:174CENSUS: 68DATE:
08/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Heidi Wheeler, AdministratorTIME COMPLETED:
06:00 PM
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“Licensing Program Analyst (LPA) Jill Nakagawa conducted a case management visit today to review staffing ratios in the building. The current census is 68; (27 in AL, 27 in both Memory Cares and 14 in Independent Living). Administrator Heidi Wheeler reports staffing as follows; AL: 2 on am, 2 on pm and 1 on NOC; 1 Med Tech each shift.. MC: 3 on am in each MC wing, 2 on pm in each MC wing and 1 shared Med Tech between the MC buildings and 2 on NOC in each MC wing with a roving Med Tech shared between the two MC buildings. RO requested an updated LIC 500. RO verified an Activity Coordinator from 8 am to 4:30 pm and Food Service staff on am and pm shifts – 7 days per week. RO requested any contractual agreements between St. John's Retirement and Peer Services Inc. Per discussions over the weekend with Administrator RO learned Peer Services Inc does consult with the facility for Marketing and HR purposes – they are not employed as a management company with St. John's Retirement, to the knowledge of Administrator HW.

LPA conducted a buildings and grounds tour and observed staff and residents in AL and both Memory Care sections of the building. No citations are being issued today.”
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
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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