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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011401227
Report Date: 12/05/2022
Date Signed: 12/05/2022 07:09:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20221130092446
FACILITY NAME:WOODROE PLACEFACILITY NUMBER:
011401227
ADMINISTRATOR:BENJAMIN BLAKEFACILITY TYPE:
772
ADDRESS:22505 WOODROE AVE.TELEPHONE:
(510) 537-1688
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:15CENSUS: 10DATE:
12/05/2022
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Margaret 'Maggie' Shapiro/Associate DirectorTIME COMPLETED:
07:15 PM
ALLEGATION(S):
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Licensee allows staff to work at facility without fingerprint clearance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a 10-day complaint investigation. LPA met with Associate Director Margaret 'Maggie' Shapiro, and informed the purpose of visit.

LPA obtained copies of client roster and staff schedule. LPA also conducted inspection and interview.

LPA verified, and per Margaret Shapiro, staff (S1) worked in the facility in the first two weeks of November 2022 prior to being fingerprint cleared and S1 didn't clear, LPA checked the Department's Guardian Portal which confirmed Shapiro's statement, and S1 is not cleared up to this time. The preponderance of evidence standard has been met, therefore, the above allegation is substantiated

.....continued on 9099c
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20221130092446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WOODROE PLACE
FACILITY NUMBER: 011401227
VISIT DATE: 12/05/2022
NARRATIVE
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Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500 .00 civil penalty is assessed. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency, civil penalty, and plan and proof of correction were discussed with Margaret Shapiro.

Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20221130092446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WOODROE PLACE
FACILITY NUMBER: 011401227
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited
CCR
81019(e)(1)
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81019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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S1 no longer works in the facility.
Licensee to read the Regulations, and ensure staff are cleared prior to allowing to work. Self-certification to be submitted by 12/06/2022.

A $500.00 civil penatly is assessed.
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-This requirement is not met as evidenced by:
-Based on interview and checking of Department's Portal, the licensee did not comply with the section above for allowing staff to work without fingerprint clearance which poses immediate safety risks to persons in care
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4