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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804226
Report Date: 05/31/2024
Date Signed: 05/31/2024 12:08:26 PM

Document Has Been Signed on 05/31/2024 12:08 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:REDWOOD COMMUNITYFACILITY NUMBER:
496804226
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, ANTONIO JRFACILITY TYPE:
740
ADDRESS:8064 WHIPPOORWILL CTTELEPHONE:
(707) 591-1127
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 0DATE:
05/31/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:39 AM
MET WITH:Antonio Martinez, ApplicantTIME VISIT/
INSPECTION COMPLETED:
12:23 PM
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Licensing Program Analysts (LPA) Cuadra and Jacky Macias arrived announced to conduct a pre-licensing inspection and was greeted by Applicant, Antonio Martinez Jr. Facility currently does not have residents in care. Once obtained, applicant will submit proof of required liability insurance.

The facility consists of a single story residence with a total of 6 bedrooms, 1 half bath, 2 full bathrooms, administration office, laundry room located in the garage, kitchen, dining room, and living room as common areas. Hospice waiver for two residents. The facility received a fire clearance approval on 3/7/2024 by the County of Sonoma Fire and Emergency Services Department for six [6] non-ambulatory residents in rooms 1-6, which two may be bedridden in rooms #3 and #4. LPAs advised applicant to submit a revised STD850 Fire Clearance request form due to some clarification needed regarding bedroom clearance for two bedridden residents. LPAs have notified analyst in the application unit and applicant as well. Applicant contacted the Fire Department to revise current fire clearance. Administrator certificate for applicant Antonio Martinez #6053650740 expires on 11/17/2024.
At approximately 9:30am LPAs/Applicant toured the building and grounds. The facility was found to be at a comfortable temperature. LPAs observed emergency supply of non-perishable food and water. All resident rooms #2-6 are furnished per regulation with a bed, lamp, and bedside table, except bedroom #1 that has required furniture not set up yet. Garage houses storage, laundry, and emergency supply of water. Cleaning supplies will be stored in a secured cabinet located in the garage. Administration office has locked cabinet that will be used for medication and file storage. Side deck connecting to Bedroom #3 has access through the fence line to the neighbors house. Water temperatures read at: 127.7, 128.4 and 132.0 degrees F which needs to be adjusted to 105-120 F degrees as stated per regulation. Continued on LIC809C...
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: REDWOOD COMMUNITY
FACILITY NUMBER: 496804226
VISIT DATE: 05/31/2024
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Continued from LIC809...
Items in kitchen that need to be addressed are: * kitchen cabinet locks to be installed for knives to be inaccessible to residents in care.

Items required to be repaired/addressed before licensure:

* Bedroom #1 needs the bed, chair, lamp, and dresser.
* Bathroom #1 needs vent rewiring and/or replacement.
* Bedroom #2: Patchwork by the faceplate needs to be painted.
* Bedroom #3 and #4 need auditory signal alarms to be installed on the door.
* Bedroom #4 needs a regular bed instead of half rail bed currently in room.
* Bedroom #5 and #6 need the metal plate for closet door handle.
* Half Bath needs the cover in the ceiling.
* All bathrooms skid mats available need to be placed in shower.
* Deck area has debris that needs to be removed.
* Side gate needs bottom latch to be removed.
* Water heater needs to be adjusted to deliver required temperature of 105 to 120 F degrees as stated per regulation.

Smoke and carbon monoxide detectors present and functioning. Two [2] fire extinguishers present and last serviced on 08/18/2023. First aid kit present with all required items. LPAs observed all required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils. Night lights in hallway present. Activity calendar and sample of menu submitted to the Centralized Application Unit (CAB).

Applicant agreed to notify Community Care Licensing once all repairs and personal accommodations are completed. LPAs will conduct a subsequent visit to confirm required repairs had been completed. LPA will notify CAB analyst. LPAs/Applicant reviewed and completed Component III orientation.
Exit interview conducted with Applicant and a copy of this report given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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