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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200181
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:18:08 PM

Document Has Been Signed on 01/24/2024 12:18 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:WOODHAVEN HOMEFACILITY NUMBER:
079200181
ADMINISTRATOR:MILAGROS N. QUEZONFACILITY TYPE:
735
ADDRESS:3319 WOODHAVEN LANETELEPHONE:
(925) 349-4225
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 6CENSUS: 6DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Ma Navarro, StaffTIME COMPLETED:
12:30 PM
NARRATIVE
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On 01/24/2024 at 09:15 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with staff Ma Navarro and explained the purpose of the visit. Administrator Milagros Quezon joined later.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan.

At 10:02 am LPA reviewed 6 residents records. At 10:45 am, LPA reviewed 4 staff records and 4 of 4 were fingerprint cleared and associated to the facility.

Continued on LIC809C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: WOODHAVEN HOME
FACILITY NUMBER: 079200181
VISIT DATE: 01/24/2024
NARRATIVE
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...Continued from 809

The following deficiency was observed during the visit:
Chemical left out and accessible
Cleaning supplies unlocked
Facility is not clean
Flies observed in bathroom
five residents are missing needs and services plan
One residents needs and services plan has not been updated
Facility did not keep one of the resident records at the facility
Three residents do not have admissions agreements
Spoiled food in drawer of fridge
Fire extinguishers has not been services since 2022



The Facility was cited, and citations can be found on the LIC 809-D. 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: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 01/24/2024 12:18 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/24/2024 at 11:36 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: WOODHAVEN HOME
FACILITY NUMBER: 079200181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having floor cleaner accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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2
3
4
The facility agrees to move the cleaner to a locked storage area. Proof of correction will be sent to CCLD by POC date.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by leaaving the laundry room that stores chemicals and cleaning supplies unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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2
3
4
The facility agrees to lock the storage area. Proof of correction will be sent to CCLD by POC date.
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 01/24/2024 12:18 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/24/2024 at 11:36 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: WOODHAVEN HOME
FACILITY NUMBER: 079200181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

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 spoiled food in drawer of fridge spilling which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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2
3
4
The facility agrees to clean the fridge and discard of any expired foods. Proof of correction will be sent to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/24/2024 12:18 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/24/2024 at 11:36 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: WOODHAVEN HOME
FACILITY NUMBER: 079200181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 dirty floors in the kitchen, dirty doors throughout the house and dirty bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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The facility agrees to clean the floors from dirt, clean the doors from marks and clean the bathrooms. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
80087(a)(1)
Building 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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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 small flies in the bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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The facility agrees to clean the bathrooms. Proof of correction will be sent to CCLD by POC date.
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/24/2024 12:18 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/24/2024 at 11:36 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: WOODHAVEN HOME
FACILITY NUMBER: 079200181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 a fire extinguishers that has not been services since 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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3
4
The facility agrees to have the fire extinguishers serviced. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onrecord review, the licensee did not comply with the section cited above three residents do not have admissions agreements which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
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3
4
The facility agrees to get the admissions agreement for the three residents. Proof of correction will be sent to CCLD by POC date.
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/24/2024 12:18 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/24/2024 at 11:36 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: WOODHAVEN HOME
FACILITY NUMBER: 079200181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents did not have a needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
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2
3
4
The facility agrees to complete a needs and services plan for all residents. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. The resident who had a needs and services plan did not have it updated since 2020 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
1
2
3
4
The facility agrees to complete a needs and services plan for all residents. Proof of correction will be sent to CCLD by POC date.
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 01/24/2024 12:18 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/24/2024 at 11:36 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: WOODHAVEN HOME
FACILITY NUMBER: 079200181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not keeping one resident record at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
POC Cleared during visit.
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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