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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011401227
Report Date: 01/09/2025
Date Signed: 01/09/2025 02:42:21 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: 15DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Natalie Lee/Associate DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff did not provide client (C1) with safe furniture resulting in client sustaining a fracture.

INVESTIGATION FINDINGS:
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On this day, 1/09/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver findings for the above allegation. LPA met with Associate Director (AD) Natalie Lee, and informed the reason for visit.

It was alleged that facility staff did not provide client with safe furniture resulting in client sustaining a fracture. The Reporting party (RP) stated that client (C1) fractured C1’s foot on 11/29/22 due to a fall from a chair. The RP stated new chairs were ordered, because the chairs in the dining cave in room and are not safe for use, and RP is unsure why the new chairs have not been put out for client use. The chairs create a fall risk to all individuals who use them, and client (C1) sustained injury on the foot when C1 fell off from the chair.

.....continued on 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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 6
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: 01/09/2025
NARRATIVE
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During the course of investigation, LPA obtained copies of the following: staff schedule; client roster; Unusual Incident Reports (UIRs). LPA also conducted inspection and interviews. LPA observed the chairs in the dining room were office chairs with wheels. Review of UIR dated 11/29/22 showed C1 fell off from the chair and staff called 9-11. C1 was transported to the hospital and came back with crutches and a wrapped ankle.

On 4/14/23, LPA discussed the chairs with Benjamin Blake, administrator (ADM), who agreed that the chairs were not safe for client’s use. ADM stated chairs were bought when the issue was brought to his attention when LPA came and discussed the issue with the staff.

Based on interviews, observation and records review, the preponderance of evidence is met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 civil penalty is assessed.

Deficiency and civil penalty were discussed with the AD.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction Form, LIC421IM Civil Penalty and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
CCR
81087(a)
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81087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
-This requirement is not met as evidenced by:
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Corrected.
The dining chairs were replaced.

A $500.00 civil penalty is assessed.
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-Based on observation, record review and interview, the licensee did not comply with the section above which resulted to C1 sustaining injury.

Civil penalty is assessed.
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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: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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: 15DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Natalie Lee/Associate DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff mismanaged clients medication.
INVESTIGATION FINDINGS:
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On this day, 1/09/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver findings for the above allegation. LPA met with Associate Director (AD) Natalie Lee, and informed the reason for visit.

LPA conducted inspection on 12/05/22 and 3/09/23. LPA observed the medications of each resident has each own container and properly labeled. The discontinued medications were also observed properly labeled. LPA obtained copy of Medication Destruction Record for discontinued medications which showed names of residents and medications with signature of facility nurse and 2 witnesses.


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

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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: 01/09/2025
NARRATIVE
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On 12/05/22, LPA interviewed the Associate Director who stated that when the facility nurse (S3) administers medications is off or out, the adjunct staff is assigned. When medications are given, S3 or the adjunct staff will give the box of medications to the clients from the medication bottles or packaging while the staff is watching. LPA interviewed S3 who stated she administers medications and stated watching clients when they take medications.

Based on information obtained, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6