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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200155
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:46:49 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
07/20/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220720145516
FACILITY NAME:WOODFIELD CARE FACILITYFACILITY NUMBER:
079200155
ADMINISTRATOR:TONI PAPIAFACILITY TYPE:
735
ADDRESS:273 WOODFIELD LANETELEPHONE:
(925) 420-5637
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Christina Limjoco, staff on duty TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff threatened client with an object
Staff did not ensure client was appropriately dressed during a video visit
INVESTIGATION FINDINGS:
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On July 26, 2022, Licensing Program Analysts (LPA) L. Ibo conducted an unannounced complaint investigation, met with staff (S2) and spoke to Licensee Jake Manalo on the phone who authorized S2 to act on his behalf and sign the reports. LPA explained the purpose of the visit with S2 and Administrator.

During investigation, LPA interviewed staff and clients. Licensee Jake Manalo self-reported an incident related to the complaint allegation.

Allegation: Staff threatened client with an object
Based on LPA interviews which were conducted and record review(s), on 7/18/2022 while C1 was on a zoom class, C1 began to show behavioral changes, C1 started throwing things around the facility, recorded video revealed S3 throwing an object to C1. Based on interview and records review, C1 did not sustain any injury from the incident.
...Continue to LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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 3
Control Number 15-AS-20220720145516
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: WOODFIELD CARE FACILITY
FACILITY NUMBER: 079200155
VISIT DATE: 07/26/2022
NARRATIVE
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Allegation: Staff did not ensure client was appropriately dressed during a video visit

Based on interview and records review, while C1 was on a recorded zoom class, she soiled her diaper, went to the bathroom and tried to change it, C1 appeared on the video that she was only wearing diaper and no pants on, this was witnessed by facility staff and other participants on the zoom call dated 7/18/2022.

The preponderance of evidence standard has been met; therefore the above allegation(s) was found to be SUBSTANTIATED.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220720145516
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: WOODFIELD CARE FACILITY
FACILITY NUMBER: 079200155
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2022
Section Cited
CCR
80072(a)(3)
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Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
This requirement is not met as evidence by:
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Administrator agreed to conduct in-service training for all staff regarding the regulation that was cited. Administrator agreed to send a copy of training topic with staff signature.
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Based on records review and interview, the licensee did not comply with Regulation, S3 threw an object to C1, which posed potential health and safety to residents in care.
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Administrator mentioned that he will "let go" (fire) the staff. The staff no longer works at the facility since 7/19/2022.
Type B
08/01/2022
Section Cited
CCR
80072(a)(1)
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Personal Rights
a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidence by:

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Administrator agreed to conduct in-service training for all staff regarding the regulation that was cited. Administrator agreed to send a copy of training topic with staff signature.
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Based on interview and records review, staff failed to provide proper clothing to C1 while conducting recorded zoom class, which posed potential health and safety to residents 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3