<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011401227
Report Date: 03/01/2022
Date Signed: 03/01/2022 06:35:34 PM

Document Has Been Signed on 03/01/2022 06:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WOODROE PLACEFACILITY NUMBER:
011401227
ADMINISTRATOR:SCHALON WOODSFACILITY TYPE:
772
ADDRESS:22505 WOODROE AVE.TELEPHONE:
(510) 537-1688
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 15CENSUS: 7DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Benjamin Blake/AdminiistratorTIME COMPLETED:
06:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Theresa McIntosh Ademi and Leesa Durst -Weisman. LPA spoke with CRT Manager Nathalie Lee who authorized Durst-Weisman to be with LPA during inspection. Benjamin Blake, administrator, arrived after about an hour.

Facility has an approved LIC808 COVID-19 Mitigation Plan.

LPA toured the facility with Durst-Weisman. LPA inspected the activity and tv rooms, kitchen, dining area, bathrooms/toilet on the first and second floors. LPA randomly selected bedrooms on the first and second floor for inspection. LPA observed screening station by the front entrance with visitor's log, hand sanitizer, and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and residents. Centrally stored PPEs inspected. Fire extinguishers were observed fully charge and tags showed serviced January 21, 2022.

LPA observed the following:
1. Cleaning supplies in unlocked cabinet under the kitchen sink.
2. Broken toilet paper holder in the second floor bathroom.
3. No COVID-19 signages in common areas.
4. No handwashing posters in the kitchen and toilets.
5. Trash bins without cover.
6. PPEs not sufficient for 30 days for 5 staff.
7. No paper towel in the bathrooms/toilets.
LPA verified that staff were not fit tested for N95 respirator.

.......continued next page (809C)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following updated documents need to be submitted by March 15, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Benjamin Blake.

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

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 03/01/2022 06:35 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/01/2022 at 06:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WOODROE PLACE
FACILITY NUMBER: 011401227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81087(l)

81087 BUILDINGS AND GROUNDS
(l) The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions, and poisons are stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed cleaning supplies in unlocked kitchen cabinet which pose immediate health and safety risks to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
1
2
3
4
Staff locked the cabinet while LPA is at the facility,
Administrator to in-service the staff and submit proof with attendees signatures by 3/02/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 03/01/2022 06:35 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/01/2022 at 06:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WOODROE PLACE
FACILITY NUMBER: 011401227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81087(a)

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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed broken toilet paper holder which poses potential personal rights risk to persons in care.
POC Due Date: 03/15/2022
Plan of Correction
1
2
3
4
Administrator to have new paper towel holder installed and submit pictures by 3/15/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
Page: 8 of 9