<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200181
Report Date: 04/15/2024
Date Signed: 04/15/2024 12:40:52 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
02/06/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240206134157
FACILITY NAME:WOODHAVEN HOMEFACILITY NUMBER:
079200181
ADMINISTRATOR:MILAGROS N. QUEZONFACILITY TYPE:
735
ADDRESS:3319 WOODHAVEN LANETELEPHONE:
(925) 349-4225
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 5DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Milagros Quezon, AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure resident is provided an adequate amount of food.
Staff does not keep facility free from pests.
Staff mishandled resident's medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/10/2024 at 12:00 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and A. Gharachorloo arrived unannounced to deliver findings for the above allegations. LPA met with Administrator Milagros Quezon and explained the purpose of the visit. During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents.

On the allegation of Staff does not ensure resident are provided an adequate amount of food. In an interview with residents, it was stated that the facility does have food, but they are not always served a full meal.

On the allegation of Staff does not keep facility free from pests. While touring the facility with staff, LPA observed cockroaches in residents’ rooms.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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 4
Control Number 15-AS-20240206134157
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: WOODHAVEN HOME
FACILITY NUMBER: 079200181
VISIT DATE: 04/15/2024
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
26
27
28
29
30
31
32
...Continued from 9099

On the allegation of Staff mishandled resident's medication. In interview S1 first stated that R1 has refused to take one if his medications. Later S1 changed their story and stated that R1 sleeps in past noon most days, when this happens S1 will not give R1 their morning medications because it is no longer morning, and the medication is prescribed for the morning.

The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) is being cited on the attached LIC 9099D.

A civil penalty of $250.00 will be assessed on today’s date for repeated violation for section number 80087(a)(1)- Keeping the facility free of Pests

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20240206134157
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: WOODHAVEN HOME
FACILITY NUMBER: 079200181
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2024
Section Cited
CCR
80076(a)(1)
1
2
3
4
5
6
7
 All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served...
1
2
3
4
5
6
7
The facility agrees to check the regulation for meal sizes and refer to this when writing up a menu. They also agreee to send a completed menu to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation, interview and record review, the licensee did not comply with the section cited above by not having large enough serving sizes for the residents.
8
9
10
11
12
13
14
Type B
04/22/2024
Section Cited
CCR
80087(a)(1)
1
2
3
4
5
6
7
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. The licensee shall take measures to keep the facility free of flies and other insects.
1
2
3
4
5
6
7
A $250.00 is assessed on this day. The facility agrees to clean. Proof of correction will be sent to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation, interview and record review, the licensee did not comply with the section cited above by having cockroaches in resident bed rooms.
8
9
10
11
12
13
14
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: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20240206134157
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: WOODHAVEN HOME
FACILITY NUMBER: 079200181
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2024
Section Cited
CCR
80075(b)(5)(B)
1
2
3
4
5
6
7
 If the client's physician has stated in... that the client is unable to determine his/her own need for nonprescription PRN medication... facility staff designated by the licensee (B) Once ordered by the physician the medication is given according to the physician's directions.
1
2
3
4
5
6
7
The facility agrees to review the regulations relating to medication. The facility also agrees to contact the doctor for medication reevaluation and additional instructions. Proof of correction will be sent to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation, interview and record review, the licensee did not comply with the section cited above by
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4