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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011401227
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:16:21 PM

Document Has Been Signed on 04/14/2023 04:16 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:BENJAMIN BLAKEFACILITY TYPE:
772
ADDRESS:22505 WOODROE AVE.TELEPHONE:
(510) 537-1688
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 15CENSUS: 12DATE:
04/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Sunita Suman/StaffTIME COMPLETED:
04:20 PM
NARRATIVE
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On this day, April 14, 2023, at 10:10 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Sunita Suman, and informed the reason for visit. LPA spoke with Benjamin Blake, administrator, over the phone who stated he can not come to the facility at the moment and authorized Sunita Suman to be with LPA during inspection. Administrator arrived at around 11:40 am.

The facility is a two story building. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, shower rooms, kitchen, computer room, art room, dining area. LPA also inspected the spare office/break-meeting room on the second floor. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced January 6, 2023. Facility has 2 in 1 carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature in one of the common bathrooms was tested and measured at 109.5 degrees Fahrenheit. Facility has LIC808 Mitigation Plan but has not submitted the Infection Control Plan

LPA reviewed 5 residents and 5 staff files, and interviewed 3 residents and 3 staff. Medications were checked and compared against records. Facility does not handle residents' cash resources.

LPA obtained copy of LIC610D Emergency Disaster Plan on this day.

Administrator to submit updated copies of the following documents by April 28, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. Infection Control Plan
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 04/14/2023
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LPA requested for file showing disaster drills conducted. Sunita Suman stated drills were conducted February 2023; however, they were not able to locate the record. Staff were not able to provide also proof that drills were conducted on 2022.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction (POC) by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Benjamin Blake.

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

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2023 04:16 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/14/2023 at 03:47 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: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81023(d)(2)
81023 Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.
(2) The drills shall be documented and the documentation maintained in the facility for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above for not having record to prove that disaster drills were conducted which poses potential safety risks to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Administrator to conduct drill and submit copy of document by 4/28/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


LIC809 (FAS) - (06/04)
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