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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200155
Report Date: 09/18/2024
Date Signed: 09/18/2024 02:09:53 PM

Document Has Been Signed on 09/18/2024 02:09 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WOODFIELD CARE FACILITYFACILITY NUMBER:
079200155
ADMINISTRATOR/
DIRECTOR:		TONI PAPIAFACILITY TYPE:
735
ADDRESS:273 WOODFIELD LANETELEPHONE:
(925) 420-5637
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Christina McGriff, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:18 PM
NARRATIVE
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On 09/18/2024 at 10:15AM Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced annual 1-Year required inspection. LPA met with Christina LImjoco McGriff, Caregiver, and explained the purpose of the visit. Christina contacted Administrator, Maria Honrada via telephone, Administrator arrived at 11:50AM The administrator currently holds a certificate (#7001513735) that expires on 11/06/2025. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) total bedrooms and three (3) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105.8 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for clients. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/25/2024 Emergency Disaster Plan was last posted on 02/02/2024. First aid kit was observed to be complete.

Continued LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WOODFIELD CARE FACILITY
FACILITY NUMBER: 079200155
VISIT DATE: 09/18/2024
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Continued from LIC809.

LPA reviewed five (5) clients' records and four (4) staff records. LPA also reviewed P&I and medications during visit.

The following forms to be updated and submitted to CCLD by 09/25/2024:

· Liability insurance.
· Surety Bond
· LIC500 (Personnel Record)
· LIC9020 (Client Roster)
· LIC308 (Designation of facility Responsibility)
· LIC400 Affidavit Regarding Client/Resident Cash Resources
· LIC610D Emergency Disaster Plan

LPA observed the following deficiency:

At 12:46PM LPA observed during file review, R2, R3, R4 and R5 were all missing current individual program plans(IPP) or Appraisal Needs and Service Plans(ANS).

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2024 02:09 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/18/2024 at 01:21 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: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.2(a)(b)(1)
(a) The licensee shall complete a Needs and Services Plan for each client as required in Sections 81068.2, 82068.2, 82568.2, 84068.2, or 85068.2.
(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
(1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having four (4) out of five (5) client's updated individual program plan (IPP) or Appraisal Needs and Service Plan, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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Administrator agreed to complete individual program plan (IPP) or Appraisal Needs and Service Plan for clients and send a self certifying email of completion to CCLD by 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
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