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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200279
Report Date: 02/09/2023
Date Signed: 02/09/2023 06:38:29 PM


Document Has Been Signed on 02/09/2023 06:38 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:REDWOOD RESIDENCEFACILITY NUMBER:
079200279
ADMINISTRATOR:EMPIG, ELISA S.FACILITY TYPE:
740
ADDRESS:861 HUMBOLDT STREETTELEPHONE:
(510) 260-0519
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY:6CENSUS: 5DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Elisa Empig, Administrator TIME COMPLETED:
06:50 PM
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On 02/09/23 at 05:20 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Elisa Empig, Administrator (ADM) was telephoned by the staff member and arrived about 5 minutes later.

Facility has a COVID-19 mitigation plan and ICP on file. LPA reviewed the resident roster, staff roster and Emergency Disaster Plan. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathroom, kitchen, front and side pathways. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap and covered garbage cans. ADM to add paper towels to shared bathroom. There is a surplus of PPE stored centrally located inside the facility that is accessible to all care staff. The facility's temperature was 71 degrees (F). Fire extinguisher was observed full. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed) and to be posted
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided to Elisa Empig, Administrator .
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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