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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200155
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:44:29 PM

Document Has Been Signed on 01/19/2024 02:44 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 FACILITYFACILITY NUMBER:
079200155
ADMINISTRATOR:TONI PAPIAFACILITY TYPE:
735
ADDRESS:273 WOODFIELD LANETELEPHONE:
(925) 420-5637
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:RAMON AZUCENA CAREGIVERTIME COMPLETED:
03:30 PM
NARRATIVE
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On 01/19/2024 at 9:45AM, Licensing Program Analysts (LPAs) Carol Fowler and Tonica Syess-Gibson conducted an unannounced 1-Year Required inspection. LPAs met with Ramon Azucena, Caregiver, and explained the purpose of the visit. Christina Limjoco, Caregiver arrived at 10:21am. The Administrator Maria Honrada arrived at 11:28am. Administrator currently holds a certificate (#6005643735) that expired on 11/06/2023. The facility’s fire clearance was approved for six (6) ambulatory residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff, and three (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/31/2023. Emergency Disaster Plan was last posted on 8/1/2023. First aid kit was observed to be complete.

Reviewed Administrator and three(3) staff files and Five(5) client files. All five (5) client files were complete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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Document Has Been Signed on 01/19/2024 02:44 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/19/2024 at 01:28 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: WOODFIELD CARE FACILITY
FACILITY NUMBER: 079200155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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
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Based on observation, the licensee did not comply with the section cited above by having lysol (3) cans, clorox, raid and spray paint located in the kitchen and the unlocked garage which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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Adminsistrator agreed to lock up the lysol, clorox, raid and spray paint at all times. Deficency cleared during visit.
Type A
Section Cited
CCR
80087(g)(1)
Building 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a unlock storage shed in the garage which has Paint, Raid, Roach Motel, Lysol, Spray Paint and Pinesol, along with an ladder standing against the wall which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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Adminsistrator agreed to lock up the lysol, clorox, raid and spray paint at all times. Deficency cleared during visit.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/19/2024 02:44 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/19/2024 at 01:51 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: WOODFIELD CARE FACILITY
FACILITY NUMBER: 079200155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

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:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above by having a non- operating dishwasher which poses a potential health and safety risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Administrator agrees to replace the dishwasher and provide photos to CCLD by the POC date.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


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: WOODFIELD CARE FACILITY
FACILITY NUMBER: 079200155
VISIT DATE: 01/19/2024
NARRATIVE
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continued from LIC809

LPAs observed the following deficiencies:

· At 10:36am, LPAs observed a non-operating dishwasher.
· At 10:41am, LPAs observed Lysol, Clorox disinfectant wipes and Raid in a unlocked cabinet underneath kitchen sink.
· At 10:49am, LPAs observed spray paint, Lysol, Roach Motel and Pine sol in an unlocked shed in the unlocked garage along with a Ladder standing against the wall.

LPAs requested the following documents to be submitted to CCLD by 02/02/2024.

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (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. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC809 (FAS) - (06/04)
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