079200155-9-26-2022-15-AS-LIBO-CJMR25-20220926123747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200155
Report Date: 09/26/2022
Date Signed: 09/26/2022 12:38:00 PM

Document Has Been Signed on 09/26/2022 12:38 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:	WOODFIELD CARE FACILITY		FACILITY NUMBER:	079200155
ADMINISTRATOR:	TONI PAPIA		FACILITY TYPE:	735
ADDRESS:	273 WOODFIELD LANE		TELEPHONE:	(925) 420-5637
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY: 6		CENSUS: 5	DATE:	09/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Christina Limjoco, Staff on duty & Sergio "Jake" Manalo, licensee/back up administrator		TIME COMPLETED:	01:00 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	On 9/26/2022 at 10:10AM , Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and met with S3, LPA called Licensee/back-Administrator (S1) and explained the purpose of the visit. At around 12:10PM, S1 arrived at the facility. Facility have census of 5. Facility has a completed mitigation plan and copy of infection control plan was received. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Infection control designated leader is the Administrator (S2). There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 78 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational. ....Contiued to LIC809C..

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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 09/26/2022 12:38 PM - It Cannot Be Edited

Created By: Leslie Ibo On 09/26/2022 at 11:54 AM

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: WOODFIELD CARE FACILITY	FACILITY NUMBER: 079200155
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be 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 by having the knives cabinet unlocked which is accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/26/2022
	Plan of Correction
1 2 3 4	Staff locked the cabinet. Administrator agreed to conduct in-service training for all staff regarding the citation cited above, a copy of training with staff names and signature need to be submitted to CCL office by 9/30/2022.

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:

Harpreet Humpal

LICENSING EVALUATOR NAME:

Leslie Ibo

LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: WOODFIELD CARE FACILITY	FACILITY NUMBER: 079200155
	VISIT DATE: 09/26/2022

NARRATIVE

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LPA observed the following:
· Unlocked knives accessible to clients in care

Technical Assistance (TA) provided to the following:

· Facility needs to conduct daily covid19 assessment for all clients and staff. All screening needs to be documented. S1 acknowledge his understanding on this topic.

· No proof of covid19 training- S1 agreed to train all staff and send a copy of training , names of staff and their signatures, these documents needs to be sent to CCL office by 9/30/2022.

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 S1.

Exit interview conducted and appeal rights copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

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