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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200181
Report Date: 01/04/2023
Date Signed: 01/04/2023 12:27:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/04/2023 12:27 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:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH: Ma Navarro, StaffTIME COMPLETED:
12:37 PM
NARRATIVE
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On 01/04/2023 at 10:57 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with staff Ma Navarro and explained the purpose of the visit. Staff called the Licensee who designated Ma Navarro to sign off on this report.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications

The following deficiency was observed during the visit:



at 11:30 am LPA observed Bags of garbage throughout the backyard and in the living room



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. Exit interview conducted.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2023
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 01/04/2023 12:27 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/04/2023 at 12:08 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: WOODHAVEN HOME
FACILITY NUMBER: 079200181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2023
Section Cited
CCR
80087(a)

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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 was not met as evidenced by:
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The facility agrees to clean up the side yard, backyard and living room. Proof of correction will be sent to CCLD by POC date.
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The facility had piles of trash in the side yard, backyard, and in the livingroom
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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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023


LIC809 (FAS) - (06/04)
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