210102866-10-7-2026-21-AS-BMOS-DYSPMM-20261012112635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102866
Report Date: 10/07/2026
Date Signed: 10/07/2026 01:54:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2026 and conducted by Evaluator Star Stevenson

COMPLAINT CONTROL NUMBER: 21-AS-20260713161448

FACILITY NAME:	REDWOODS, THE		FACILITY NUMBER:	210102866
ADMINISTRATOR:	ELENA DAVIDENKO		FACILITY TYPE:	740
ADDRESS:	40 CAMINO ALTO		TELEPHONE:	(415) 383-1600
CITY:	MILL VALLEY	STATE: CA	ZIP CODE:	94941
CAPACITY:	150	CENSUS: 128	DATE:	10/07/2026
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Kyle Ruth-Islas-Chief Executive Officer		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not provide adequate food service to residents in care
Due to neglect, resident sustained a pressure injury

INVESTIGATION FINDINGS:

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On 10/07/2026, Licensing Program Analyst (LPA) Stevenson conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Chief Executive Offier (CEO) Kyle Ruth-Islas.

During the investigation, LPA reviewed records, conducted interviews with staff and outside parties, and made observations. The first compliant alleged that staff do not provide adequate food services to Residents in care noting concerns specifically for the dietary management of Residents R1, R2 and R3.
The Redwoods is noted to have on-site Dietary Services and Register Dieticians, along with documented considerations for dietary restrictions and textures, as well as percentages of foods consumed. The facility also has published menus that take into consideration dietary and texture restrictions as set out by each Residents doctor.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260713161448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: REDWOODS, THE	FACILITY NUMBER: 210102866
	VISIT DATE: 10/07/2026

NARRATIVE

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Continued from LIC9099

A review of R1, R2 and R3 latest Physician’s Reports (LIC602) indicate that all had “no special diet” or “No (dietary) Restrictions”.

A separate review of R1, R2 and R3’s Service Plan Reports developed by The Redwoods indicates R2 “will maintain independence with eating/meals and is on a regular balanced diet and needed encouragement food and fluid consumption”, while R3 “will maintain independence with eating/meals, is independent with eating and drinking and is on a regular diet”. A service plan for R1 dated 06/11/2026 indicates R1 will be “encouraged oral intake, and offer preferred foods and snacks daily and offer fluids frequently throughout the day and that R1 is on a regular textured diet and NAS (no added salt) and encourage food consumption and fluids”

An interview with W1, had W1 praising the nutrition efforts for R1 by The Redwoods with W1 noting R1 had an opportunity to order whatever they wanted and often chose items off the dietary menu with ala-cart selections”. W1 also revealed that R1 was never on a restricted diet and “because of their age, W1 encouraged R1 to have whatever they wanted."
A review of a People Roster Report of The Redwoods revealed that R2 and R3 were on “General” Diets (without concern for salt or carbohydrate consumption) and that R2 was on a regular textured diet, while R3 was on a SB6- diet (Soft Bite Size) textured diet. An interview with staff S2 and S3 revealed that residents were always evaluated for dietary restrictions, as well as food and fluid textures they could consume at The Redwoods.
Evaluation of the outside notes of Home Care and Hospice care indicate R1 was on “Regular diet” and “No Therapeutic diet” (e.g. low salt, diabetic, low cholesterol), in addition hospice notes indicate R1 was eating just 0-25% of meals and was missing multiple teeth and that a fluid restriction was “discontinued”.

Because interviews, document review and personal observations of this LPA reveal a sophisticated food and nutritional service program for residents at The Redwoods that both, take into consideration medical factors and food preferences while maximizing Residents independence, the allegation that “Staff do not provide adequate food services to residents in care" is UNSUBSTANTIATED.

Continued on LIC9099-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260713161448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: REDWOODS, THE	FACILITY NUMBER: 210102866
	VISIT DATE: 10/07/2026

NARRATIVE

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Continued from LIC9099-C

A second allegation received by Community Care Licensing (CCL) on 07/13/2026 alleged, that due to neglect, Resident (R1) sustained a pressure injury.

Complainant also suggested that an “ill-fitting wheelchair too small for R1” and insufficient wound care supplies like bandages, tape, and antibiotics contributed to a pressure injury of R1.

A review of records for R1 indicated R1 required the use of a wheelchair and developed a stage 3 and 4 pressure injuries while on Hospice care.

Documents indicate that dietary considerations around wound healing were considered by The Redwoods, but also that R1 ultimately had poor consumption of nutrition with Home Care and Hospice notes indicating R1 had a poor appetite, missing teeth, ill-fitting dentures, tooth decay, difficulty chewing, early satiety and consumption of just 0-25% of meals per caregivers. Documents also revealed that staff at The Redwoods encouraged consumption of both solids and liquids and that R1 had independent choice of food selections.

LPA observed numerous cabinets of wound supplies available at the Facility (photos taken) and noted that when R1’s wounds began to develop, it was Home Care and then Hospice that provided wound care and wound care orders. Home Care notes from 05/05/2026 had a visiting RN being alerted by staff of The Redwoods of discomfort of R1’s right toes and a small area of redness on R1 left foot. Another note from Home Care indicated that R1 “might benefit from sturdier shoes (R1 was wearing Crocs) and that the skin on R1’s feet were intact with no evidence of rubbing/friction” and efforts were also made for R1 to be seen by a podiatrist.

A note on 05/28/2026 indicated that an outside agency would be providing wound care supplies and wound care two (2) times a week and that staff (at The Redwoods) would be performing wound care 2 times a week, “as needed for soiling or dislodgement”. This LPA received no documentation from an outside agency or The Redwoods, that staff at the Redwoods performed dressing changes for R1. A discussion with S5 indicates The Redwoods has Licensed Vocational Nurses (LVNs) on staff 7 days a week for all shifts.

Continued on LIC9099-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20260713161448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: REDWOODS, THE	FACILITY NUMBER: 210102866
	VISIT DATE: 10/07/2026

NARRATIVE

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Continued from LIC9099-C

An interview with W1 reveals that R1 was in a wheelchair that W1 suspected of being “too small” for about 6 weeks. W1 revealed that the wheelchair in question was supplied by Kaiser and W1 had requested a larger wheelchair from Kaiser but felt Kaiser was “dragging their feet” on a replacement and that W1 was hopeful R1 would simply resume walking again. W1 felt it was Kaiser’s responsibility to make any changes to R1’s wheelchair.

Documents revealed, R1 presented to the Emergency Department with non-healing pressure sore of the right leg and that R1’s Responsible Party after consultation with care team, did not think that R1 would tolerate surgery or surgical debridement and opted for conservative treatment of the wounds. R1 was noted to be admitted to Hospice Care on 06/10/2026 with Hospice notes indicating that “(Redwood) Caregiver demonstrated knowledge of pressure sore prevention and repositioning…and LA (Low-Air loss) mattress was delivered the same day.”

Finally, Hospice notes on 06/10/2026 indicate that The Redwoods initiated a request to increase wound care for R1 from 2 days to 7 days a week provided by Hospice with Hospice noting they had “ordered Dakins solution, left at least 4 or 5 gauze rolls, 10-4x4 gauze and 5-6 non-adhering dressing, but that Kaiser was supposed to send (wound) supplies but did not”

Because of conflicting information about whether neglect by The Redwoods caused R1 to sustain a pressure injury, the complaint is Unsubstantiated.

A finding of unsubstantiated means, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

No citations are cited

Report was reviewed with CEO Kyle Ruth-Islas and report.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

LIC9099 (FAS) - (06/04)

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