The Redwoods, a Community of Seniors
40 Camino Alto, Mill Valley, CA 94941 · Marin County · 58 certified beds · avg 43 residents/day · certified since Apr 4, 2005
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 12, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 23, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 27, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 17, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 18, 2022 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 14, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 18, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 14, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (42)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 22, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 22, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 22, 2026 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| May 22, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 22, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| May 22, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Aug 19, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Apr 23, 2025 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Jul 12, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 27, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 18, 2022 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 18, 2022 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 18, 2022 | F · Potential for harm, facility-wide | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Feb 18, 2022 | F · Potential for harm, facility-wide | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 18, 2022 | F · Potential for harm, facility-wide | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 18, 2022 | F · Potential for harm, facility-wide | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 18, 2022 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Feb 18, 2022 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 18, 2022 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Feb 18, 2022 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 18, 2022 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Feb 18, 2022 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 18, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 13 | 2 | G ▲ |
| 2023 | 2 | 1 | G ▲ |
| 2024 | 12 | 1 | G ▲ |
| 2025 | 4 | 0 | D |
| 2026 | 11 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $103,054, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jul 12, 2024 | Fine | $54,421 |
| Jul 12, 2024 | Payment Denial | 14 days from Aug 9, 2024 |
| Sep 27, 2023 | Fine | $48,633 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.21 | 4.31 | 3.95 | top 11% in California; top 10% in the U.S. |
| Registered Nurse hours | 0.59 | 0.61 | 0.69 | top 33% in California; top 49% in the U.S. |
| Weekend total nurse staffing | 4.73 | 3.90 | 3.50 | top 10% in California; top 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.44 | 0.51 | 0.48 | top 39% in California; top 41% in the U.S. |
| Total nursing staff turnover (%) | 40.4 | 36.7 | 45.8 | bottom 37% in California; top 37% in the U.S. |
| RN turnover (%) | 55.6 | 38.1 | 42.9 | bottom 20% in California; bottom 28% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.65, RN 0.53, weekend 4.22. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bikle, Daniel | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Davidenko, Elena | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/30/2024 |
| Davidenko, Elena | Individual | ADP of the SNF | NOT APPLICABLE | 09/30/2024 |
| Flynn, Andrea | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Gordon, Peter | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Harmon, Robert | Individual | Corporate Director | NOT APPLICABLE | 01/01/2020 |
| Hines, Janet | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Imwalle, Brittany | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Joachim, Caroline | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Lucaccini, Margaret | Individual | Corporate Director | NOT APPLICABLE | 01/01/2022 |
| Meislin, Vera | Individual | Corporate Director | NOT APPLICABLE | 01/01/2022 |
| Miller, Burton | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Picetti, Dominic | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2023 |
| Picetti, Dominic | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Pollack, Kendra | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Rand, David | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Reynolds, Robert | Individual | Corporate Director | NOT APPLICABLE | 01/01/2020 |
| Ronald, Richard | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Ruth-Islas, Kyle | Individual | Corporate Officer | NOT APPLICABLE | 11/14/2022 |
| Ruth-Islas, Kyle | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/14/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| South Marin Health & Wellness Center | 3.5 mi | Greenbrae, CA | ★★★★☆ | 3/5 | |
| The Tamalpais | 3.6 mi | Greenbrae, CA | ★★★★★ | 4/5 | |
| San Rafael Healthcare & Wellness Center, LP | 5.6 mi | San Rafael, CA | ★★☆☆☆ | 2/5 | |
| Marin Post Acute | 7.5 mi | San Rafael, CA | ★★☆☆☆ | 2/5 | abuse |
| Villa Marin | 7.6 mi | San Rafael, CA | ★★★★★ | 4/5 | |
| Pine Ridge Care Center | 8.1 mi | San Rafael, CA | ★★★★★ | 3/5 | |
| Northgate Postacute Care | 8.1 mi | San Rafael, CA | ★★☆☆☆ | 2/5 | abuse |
| Professional Post Acute Center | 8.1 mi | San Rafael, CA | ★★★☆☆ | 2/5 | |
| St. Anne's Home | 8.4 mi | San Francisco, CA | ★★★☆☆ | 4/5 | |
| Smith Ranch Skilled Nursing & Rehabilitation Cente | 8.6 mi | San Rafael, CA | ★★★☆☆ | 2/5 | |
| Laurel Heights Community Care | 8.8 mi | San Francisco, CA | ★★★★★ | 4/5 | |
| Pacific Heights Transitional Care Center | 8.9 mi | San Francisco, CA | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 555826.