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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011401227
Report Date: 04/24/2024
Date Signed: 04/24/2024 07:01:45 PM

Document Has Been Signed on 04/24/2024 07:01 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/
DIRECTOR:		BENJAMIN BLAKEFACILITY TYPE:
772
ADDRESS:22505 WOODROE AVE.TELEPHONE:
(510) 537-1688
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 15CENSUS: 10DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Theresa McIntosh-Adyemi/Interim ManagerTIME VISIT/
INSPECTION COMPLETED:
07:05 PM
NARRATIVE
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On this day, April 24, 2024, at 1:00 p..m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Sunita Suman, facility nurse, and Theresa McIntosh-Adyemi, interim manager, and informed the reason for visit.

The facility is a two story building. LPA toured the facility inside out with the interim manager. LPA inspected the computer room, dining room, kitchen, art room, bedrooms, shower rooms, bathrooms, front, side and backyard. LPA also inspected the spare office/break-meeting room on the second floor. Supplies of food were observed good for 2 days of perishables and 7 days of non-perishables. Storages for cleaning supplies were observed locked.

Fire extinguishers were observed fully charge with tags showed serviced January 30, 2024 Facility has 2 in 1 carbon monoxide and smoke detector that was tested and observed functional. Hot water temperature in one of the common bathrooms was tested and measured at 108.7 degrees Fahrenheit.

Facility has LIC808 Mitigation Plan. LPA requested for LIC9282 in April 14. 2023 which the facility has not submitted up to this day.

LPA reviewed 5 residents and 5 staff files, and interviewed 3 residents and 3 staff. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.


......continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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: 04/24/2024
NARRATIVE
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LPA observed the following:
-at 1:15 to 1:45 p.m., almost all the trash cans without lids.
-at 2:00 p.m., no evacuation chair in each of the stairwell.
-at 3:10 p.m., facility does not have record showing disaster drill is conducted every quarter. Record showed last conducted 3/18/24 and no record for 2023.
-at 3:30 p.m., staff (S4 and S5) do not have LIC503 Health Screening on file.
-at 3:40 p.m., staff (S5) First Aid certificate on file expired 11/04/23.

Administrator to submit updated copies of the following documents by May 8, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

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

Deficiencies and plan and proof of correction were discussed with the interim manager.

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: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/24/2024 07:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/24/2024 at 05:51 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: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81095.5(a)(2)(D)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:  (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. 

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 in [trash cans without lids which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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2
3
4
Administrator to purchase trash cans with foot operated pedal lids, and submit proof of purchase by 5/08/24.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in not doing drill every quarter which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Administrator to have drill conducted at least every quarter and submit self-certification by 5/08/24.
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: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/24/2024 07:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/24/2024 at 05:51 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: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

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 in not having evacuation chair in each of the stairwell which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Administrator to purchase evacuation chair for each of the stairwell and submit proof of purchase by 5/08/24.
Type B
Section Cited
CCR
81075(f)
81075 Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in S5's first aid certificate expired which poses a potential safety risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Administrator to have the staff complete the training and submit copy of certificate by 5/08/24.
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: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/24/2024 07:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/24/2024 at 06:23 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: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81065(g)(2)
81065 Personnel Requirements
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.
(2) A health screening report signed by the person performing such screening shall be made on each person specified above….

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record review, the licensee did not comply with the section cited above in staff (S4 and S5) not having LIC503 Health Screening on file which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Administrator to have the staff health screened and submit copies of LIC503 by 5/08/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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