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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102866
Report Date: 09/12/2022
Date Signed: 09/13/2022 10:08:59 AM

Document Has Been Signed on 09/13/2022 10:08 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:REDWOODS, THEFACILITY NUMBER:
210102866
ADMINISTRATOR:CATHERINE SCOTTFACILITY TYPE:
740
ADDRESS:40 CAMINO ALTOTELEPHONE:
(415) 383-2741
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 150CENSUS: 120DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Catherine Scott - AdministratorTIME COMPLETED:
12:42 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation Department learned there are related deficiencies observed during the visit. LPA met with Catherine Scott - Administrator. Following item were observed during investigation visits:

Department observed during resident’s R4 file review and staff S2 interview on 8/17/2022 that resident R4’s physician assessment dated 7/15/2022 has a diagnostic of Type 2 diabetes; resident came back from SKNF with order for Humalog 100 units 3x a day and glucose testing needed; resident R4 physician’s assessment states that R4 can’t manage his medication including injections and glucose testing; on 7/21/2022 facility faxed doctor stating “ Resident back from SNF insulin VIAL order sliding scale,” and requesting a new order for Lispro inulin – “Insulin pen need to be available in order for Medication Technician to coach resident on getting it once nurse is not available during weekend.” According to records reviewed Lisopro filled 8/2/2022 and for the month of August 2022 resident R4 has self-administer its own injection and glucose test from 8/1/2022 to 8/16/2022. (see copy of documentation, LIC 811 confidential name list, LIC 809-D) Per Title 22 Regulations #87628 Diabetes “The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.” (Continued LIC 809-C)
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: REDWOODS, THE
FACILITY NUMBER: 210102866
VISIT DATE: 09/12/2022
NARRATIVE
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In addition, facility have not submitted Department with incident reports that are required for any missed medication, refusal of medication, and/or 911 calls including when a resident have refused and/or have been taken to ER as follows: Resident R1 medication refusal on 8/12/2022 and 7/6/2022 for 5 days; resident R2 for missing medications of Losartan from 8/2 to 8/10/2022, Amoldine 5/22 to 5/23/2022, and Elequilis from 4/23 to 4/26/2022; Resident R3 Azelastine 8/7/2022 “not administered”, Omeprazole 5/1 to 5/5 and 6/20 to 6/30/2022 “not available”, Valsartan 6/1 to 6/14/2022 “not administered”, 911 contacted for fall on 6/23/2022 – family refused that resident was transported to ER; Resident R4 medication refusal 5/20/2022, 911 contacted on 4/14/2022 fue to a fall, resident sent to ER due to a fall on 6/12/2022, medication refusal on 6/23/2022 w/ 911 contacted and ER refusal by resident, and ER visit on 6/24/2022. (see copy of documentation on file, LIC 811 confidential name list, LIC 809-D)

Department is requesting a death certificate for resident R5 that passed away on 9/4/2022.


Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and 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 and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2022 10:08 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 09/08/2022 at 03:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: REDWOODS, THE
FACILITY NUMBER: 210102866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2022
Section Cited
CCR
87628

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87628Diabetes This equirement is not met as evidenced by: Based on observation,interview, & record review licensee didn't comply w/section cited above in 1outof1 resident w/diabetes which poses an immediate
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Facility to ensure that to accept & retain resident with diabetes if not able to perform his/her own glucose testing and/or able to administer injections that a skilled professional will be available to perform these tasks
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health & safety risk to persons in care.Resident R1 has LIC 602 stating that R1 is not able to administer insulinshots or glucose testing.Per interviews & file review R1 has self administer injections& glucose testing.
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as needed. Administrator to submit self certification that there is a skilled professional conducting testing & plan for glucose testing by POC due date of 9/13/22 in order to clear this citation and avoid civil penalties.
Type B
09/26/2022
Section Cited
CCR87211

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87211 Reporting Requirements - This requirement is not met as evidenced by:Based on interview & file review facility didn't comply w/this section for 4 of 4 residents which posses potential health, safety, personal rights risk to
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Facility to ensure that all Incident & Death Reports are submitted to CCLD according to Title 22 Regulations. Licensee to submit a self certification that facility understands this regulation
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residents in care.Depart.learned that there were multiple incident reports for R1,R2,R3, &R4 that were not submitted to CCL such as refusal of meds, missing meds, 911calls w/&/out residents being transported to ER(copies)
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and plan on how facility will ensure that this requirement will be followed by facility to CCL by POC date of 9/26/2022 in order to clear this citation.
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 Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


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