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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102866
Report Date: 01/29/2025
Date Signed: 01/29/2025 02:48:56 PM

Document Has Been Signed on 01/29/2025 02:48 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:REDWOODS, THEFACILITY NUMBER:
210102866
ADMINISTRATOR/
DIRECTOR:		KYLE RUTH-ISLASFACILITY TYPE:
740
ADDRESS:40 CAMINO ALTOTELEPHONE:
(415) 383-2741
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 150CENSUS: 110DATE:
01/29/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Kyle Ruth-Salas, Executive Director
Elena Davidenko, Administrator		TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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At approximately 9:45am, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Elena Davidenko and Executive Director, Kyle Ruth-Salas. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL) on 12/26/2024.

Incident report states on 12/25/2024 Resident 1 (R1) had pressed their emergency pendant in response to a fall to request staff assistance at approximately 2:49am. The security guard monitoring the system did not notify staff on duty of the alert and the call for assistance was not answered in a timely manner. (Deficiency Cited)

Administrator conducted an in-service training on response protocols and training on pendant response. Deficiency was cleared during visit.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), and Appeal Rights discussed and provided to Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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Document Has Been Signed on 01/29/2025 02:48 PM - It Cannot Be Edited


Created By: Anthony Loera On 01/29/2025 at 12:14 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
CCR
87415(a)(5)

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87415 Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m...shall be available as indicated below to assist in caring for residents in the event of an emergency...(5) In facilities required to have a signal
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Adminstrator conducted an in-service training on response protocols and training on pendant response. Deficiency was cleared during visit.
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system, at least one night staff person shall be located to enable immediate response to the signal system. This requirement was not met as evidence by: Based on interview and document review, Administrator did not ensure that R1 was assististed in a timely manner.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Anthony Loera
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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