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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011401227
Report Date: 12/05/2022
Date Signed: 12/05/2022 07:12:24 PM

Document Has Been Signed on 12/05/2022 07:12 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: 10DATE:
12/05/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Margaret 'Maggie' Shapiro/Associate DirectorTIME COMPLETED:
07:15 PM
NARRATIVE
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On this day, December 5, 2022, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 2 complaint (Complaint # 15-AS-20221130092446). LPA met with Associate Director Margaret 'Maggie' Shapiro, and informed the reason for visit.

LPA toured the facility including but not limited living room, kitchen, dining room, bathroom, backyard. LPA randomly selected 5 rooms, 2 on the first floor and 3 on the second floor. Food supplies were observed sufficient good for 7 days of non-perishables and 2 days of perishables. Hot water temperature was tested on one of the lavatories in the shower room on the first floor.

LPA observed the following:
  • At 5:00 pm, hot water temperature was tested and measured at 129 degrees Fahrenheit.
  • Missing door cabinet in one of the bathrooms on the second floor.


Upon interview and verification, LPA learned from Margaret Shapiro that one of the residents was sent out 3 times. The first time this particular resident was sent out was November 27 or 28, 2022 and facility failed to report to the Department followed by a written report.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. A $250.00 civil penalty is assessed for repeat violation of section #81087(a) within 12 month period. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed. Exit interview conducted. Appeal Rights, LIC421FC 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
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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Document Has Been Signed on 12/05/2022 07:12 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/05/2022 at 05:31 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: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2022
Section Cited
CCR
81088(e)(1)

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81088 Fixtures, Furniture, Equipment, and Supplies. (e)(1) Hot water temperature controls shall be maintained ... temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and
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Licensee to have the water temperature adjusted and do in-service training to ensure hot water temperature is kept within Regulations range, Proof to be submitted by 12/05/2022.
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not more than 120 degrees F (48.8 degrees C).
-This requirement is not met as evidenced by:
-Based on inspection, the licensee did not comply with the section above for hot water temperature at 129 degrees Fahrenheit which poses immediate safety risk 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/05/2022 07:12 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/05/2022 at 05:42 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: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
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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Licensee to have the cabinet door installed and submit picture by 12/19/2022.

A $250.00 civil penalty is assessed.
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-Based on observation, the licensee did not comply with the section cited above. LPA observed missing bathroom cabinet door which poses potential personal rights risk to persons in care. This is a repeat violation withing 12 month. First citation was issued on 3/01/2022.
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Type B
12/19/2022
Section Cited
CCR81061(b)(1)(E)

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81061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events.. a report shall be made to the licensing agency within the agency's next working day..In addition, a written report shall be submitted to the licensing agency within seven days...:
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Licensee to submit incident reports by 12/19/2022. In addition, licensee to ensure reports are made and submitted in timely manner.
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(E)Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
-This requirement is not met as evidenced by:
-Based on interview, the licensee did not comply with the section above for failure to repoprt an incident which poses potential personal rights risk to person 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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