Redwood Retreat

Allegation investigated: Staff did not address resident's change of condition. Staff are not providing adequate meal service to resident.

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegations. LPA was greeted by caregiver. Administrator Eric Moessing could not come to the facility but was available by phone and gave permission for caregiver to sign report. Complaint alleges staff did not address resident's change of condition. Complainant states that on 4/15/2026 resident (R1) had a left sided facial droop lasting about 20 minutes, symptoms resolved within 20 minutes. During investigation, LPA reviewed medical records for R1 which indicate they were seen at the emergency room on 4/15/26 and diagnosed as having a Transient Ischemic Attack (TIA). During investigation, LPA conducted interviews with facility staff present on 4/15/26. All parties interviewed report that R1 was monitored by facility staff throughout the day. LPA observed communication between R1 and R1’s responsible party documented via text. Staff reported observing R1’s speech to be normal, not Continued on 9099C... Unsubstantiated Continued from 9099... slurred. LPA observed communication involving pictures and videos sent by facility staff to R1’s responsible party, with time stamps beginning at 11:54am through 2:02pm and ending at 4:35pm. LPA reviewed videos and pictures sent from staff to R1’s responsible party. Staff report they did not observe any changes in R1’s condition. R1’s responsible party then came to the facility, asked to use the facility computer, and after speaking with staff called 911. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges staff are not providing adequate meal service to resident. Complainant states facility does not wake R1 up for meals and that staff wait for R1 to wake up naturally. During investigation, LPA received conflicting accounts of requests to wake R1 up for meals. Additionally, LPA reviewed physician’s report for R1. Report indicates no special dietary requirements other than low salt. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with caregiver and a copy of this report given.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 21-AS-20260416130250

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on complaint #21-AS-20260416130250. During investigation, it was revealed that resident (R1) has a doctor's directive to have blood sugar checked every morning. LPA reviewed physician's report for R1. Current medication orders include a glucose monitor, lancets, and test strips. LPA discussed with licensee the current doctor's orders for glucose monitoring. Licensee advised that R1 does not have any current orders for diabetic medication as they do not have diabetes. Licensee was not aware of any glucose monitoring supplies prescribed to R1 by their doctor. Additionally, licensee advised LPA that facility does not have a pharmacy and therefore verbally advises resident's responsible parties, upon admission, that the facility will not be responsible for filling medication orders. Facility will always help residents with self-administration of medication, but does not fill or refill prescriptions. Facility staff interviewed report never having been asked to monitor blood sugar for R1 nor have they ever received any glucose monitoring supplies with which to test. Licensee will ask for clarification from R1's doctor and responsible party as to the doctor's orders for glucose monitoring and if required facility will implement helping R1 with testing according to doctor's orders. LPA discussed with licensee ensuring documentation is present for all residents and responsible parties outlining facility medication ordering procedures and policies. No deficiencies cited during this visit. Exit interview conducted with caregiver and a copy of this report given.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christi Coppo conducted an unannounced visit to facility to open complaint 21-AS-20260416130250. LPA was greeted by caregiver. Administrator Eric Moessing arrived later. Upon entering the facility LPA observed very strong odor of urine (deficiency cited, see 809D). Per caregiver, three (3) residents (R1, R2, and R3) in particular have strong urine odors in their room. LPA toured rooms of said residents and found each room to have a profound and pervasive odor of urine. One resident (R1) in particular had an odor in their room so pervasive it was overpowering. Per caregiver, R1 is very difficult to move so they do not move them very often. LPA discussed with Administrator all three residents and the odor of urine present in their rooms. LPA discussed providing new mattresses or identifying the source of the lingering odor and addressing it with either new items or waterproof protection. This includes any furniture made of cloth material, mattresses, and linens. Per caregiver, R1 refuses to shower, R2 refuses to wear underwear or a brief, and R3 does not like their brief to be changed. All of these reasons led to the state of urine odor within the facility. Per caregiver, they do not have a regularly scheduled incontinence check; if they observe the resident as having a full brief, then they change it. LPA, Administrator and caregiver discussed some options to implement an incontinence check and to chart the checks performed. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 20, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: May 4, 2026

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors and incontinence. This requriement not met by licensee as evidenced by: Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that facility and resident rooms have odor of urine, which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: Facility to purchase either a new mattress or a mattress in good condiction and is comfortable for residents R1, R2, and R3. Mattresses to be waterproof or have waterproof cover. Additionally, facility will implement an incontinence check schedule that caregivers will follow and chart changes. Proof of purchase or photographic proof of changed mattress with waterproof pads due to CCL by plan of correction due date. Additonally, facility to submit one week of incontenence care checks performed by plan of correction due date. Resident refusals will also be documented.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Inspection of facility and was welcomed by Janette (caregiver), Administrator, Eric Moessing was contacted by staff and arrived during inspection. Facility is a single story RCFE with 13 bedrooms and a fire clearance for 15 Non ambulatory of which 2 may be bedridden. Facility granted hospice waiver for 6. There is currently a total of 13 residents, 6 of which have dementia diagnosis, with 1 resident currently under Hospice care. On 9/29/2025 at approximately 9:30 AM LPA initiated a tour of the facility with staff and made the following observations: Facility was a comfortable temperature and all exits were free from obstructions. Activity calendar observed and menus posted. Required postings were observed. Resident rooms were furnished per regulation. Water temperature in resident's bathroom faucets measured between 108.3 degrees F and 116.2 degrees F within Title 22 acceptable range of 105 to 120 degrees F in 7 out of 7 resident’s bathroom faucets. Extra hygiene products and linens were available. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. Toxins are in locked cabinet in hallway closet, under kitchen sink & in locked laundry room. Medications are centrally stored in the medication cabinet in the kitchen which was locked at the time of inspection, overflow of medications are stored in 2 locked cabinets in family room. Fire extinguisher was last inspected 10/11/2024. Facility has sprinkler system and hard-wired smoke alarm system that is maintained by vendor, last service was conducted 7/14/2025. Combination Smoke alarm and Carbon Monoxide detectors tested and found to be working. Auditory alarms were functional at the time of visit. Continue on LIC809-C Continue from LIC809 File review was initiated at 11:00 am. Five staff files and five resident files along with 2 resident medication records were reviewed. Five resident records were reviewed finding all but 1 resident have current needs and service plans updated (see LIC9102 TA) and all residents have Physicians Assessments per regulations. At approximately 12:20PM staff records were reviewed. All staff requiring background checks have been cleared and associated to facility. All staff have required training and other required documents. All staff have required First Aid and CPR certificates. At approximately 1:20 PM Medications of 2 out of 2 residents were found to be given according to physician’s directions. Centrally Stored Medication Records (CSMR) were found to be complete and accurate on 9/29/2025. Disaster Drills are conducted quarterly and different shifts, with the last one being conducted on 9/16/2025. Administrator Certificates for Eric Moessing, 7005070740, expires 8/16/2026. No citations given during today’s inspection. LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/17/2025: LIC 308 Designated (if changes) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Sep 29, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Required Inspection of the facility and was welcomed by Janette (caregiver), Administrator, Eric Moessing was contacted by staff and arrived during inspection. There is a total of 15 residents, 8 of which have dementia diagnosis. There are 2 residents’ currently on Hospice. Facility has clearance for 15 non-ambulatory, 2 of which can be bedridden and a Hospice Waiver Approval for 6. LPA initiated a tour of the facility with staff at 10:20 am and made the following observations: Facility was a comfortable temperature and free from obstructions. Activity calendar observed and menus posted. Required postings were observed. Resident rooms were furnished per regulation. Water temperature in resident's bathroom faucets measured between 111.2 degrees F and 113.5 degrees F within Title 22 acceptable range of 105 to 120 degrees F in 4 out of 4 resident’s bathroom faucets. Extra hygiene products and linens were available. Bathrooms had required bathmats and grab bars. Toxins are in locked cabinet in hallway closet, under kitchen sink & in locked laundry room. Medications are centrally stored in the medication cabinet in the kitchen which was locked at the time of inspection; although LPA observed two containers of medications for med pass on kitchen counter, accessible to residents in care 87465(i)(see pic)(see LIC809-D). Fire extinguisher was last inspected 10/6/2023. Facility has a hard-wired smoke alarm system that is maintained by a vendor. Facility's last service was conducted 7/2024. Carbon Monoxide detectors tested and found to be working. Auditory alarms were functional at the time of visit. File review was initiated at 11:15 am. Five staff files and five resident files along with 2 resident medication records were reviewed. All staff have required First Aid and CPR certificates. One staff (S1) out of five staff do not have required TB test on file (see LIC 809-D). One out of 5 staff (S2) does not have required Health Screening (see LIC-809-D). Continues on LIC 809C... Continued from LIC809 All staff requiring background checks have been cleared and associated to facility. All staff have required training. At approximately 12:15 PM resident records were reviewed finding all residents have current needs and service plans updated and all but 1 resident (R1) has updated Physicians Reports (see LIC 809-D). At approximately 1:20 PM Medications and medication records were reviewed and found to be up to date. LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any information. Disaster Drills are conducted quarterly with the last one being conducted on 7/26/2024. Administrator Certificates for Administrator Eric Moessing, 6017309740, expired on 8/16/2024 although LPA observed, proof of pending certificate. 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. LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/7/2024: LIC 308 Designated (if changes) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate (when receive) Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Sep 16, 2024