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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200155
Report Date: 06/15/2022
Date Signed: 06/15/2022 11:06:11 AM

Document Has Been Signed on 06/15/2022 11:06 AM - 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: 6DATE:
06/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lani Zazueta, staffTIME COMPLETED:
11:30 AM
NARRATIVE
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On this day, June 15, 2022, LPA L. Ibo arrived to the facility unannounced to conduct case management related to incident report received 5/24/2022 and met with staff, Lani Zazueta , LPA called licensee Jake Manalo and informed her the purpose of visit.

Licensee self- reported that on 5//24/2022 C1 was missing and was found at the neighborhood. LPA conducted interview; staff stated that C1 was found at a nearby store. Staff assess C1, no injuries noted.

Deficiencies are cited from Title 22 California Code of Regulations (see 809Ds). Failure to submit proof of corrections (POCs) by plan or 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 Jake Manalo over the phone.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to S1.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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 06/15/2022 11:06 AM - It Cannot Be Edited


Created By: Leslie Ibo On 06/15/2022 at 10:51 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: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.
-This requirement is not met as evidenced by:

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Administrator agreed to do the following and submit proof by 6/16/2022
1. In-service the staff and submit copy of training with attendees’ signatures.
2. Update care plan.
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-Based on records review and interview, the licensee did not comply with Regulation, C1 was missing and found at near by store, which posed immediate health and safety to residents in care.

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3. Auditory signal for sliding door and front door. (pictures need to be sent to CCL office by 6/17/2022)


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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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


LIC809 (FAS) - (06/04)
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