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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200361
Report Date: 04/06/2023
Date Signed: 04/06/2023 02:43:58 PM

Document Has Been Signed on 04/06/2023 02:43 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:WOODBRIDGE HOMEFACILITY NUMBER:
079200361
ADMINISTRATOR:JAMES MERCADOFACILITY TYPE:
735
ADDRESS:1854 MT. GOETHE WAYTELEPHONE:
(925) 778-1522
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 5CENSUS: 5DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Melissa Cortez, AdministratorTIME COMPLETED:
03:30 PM
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On 04/06/23 at 1:30PM, Licensing Program Analysts (LPAs) D Panlilio and L Holmes arrived unannounced to conduct an unannounced annual required inspection. LPAs met with administrator (ADM) and explained the purpose of the visit. During visit, LPAs observed one client relaxing inside his bedroom. The other 4 clients were attending their individual day programs during visit.

LPAs toured the facility inside and out with ADM. LPAs observed COVID-19 screening station at the front entrance with no touch temperature probe, visitor's logs, hand sanitizer and additional masks and gloves available for staff, visitors and clients.

LPAs inspected the living and family rooms, kitchen, dining room, bedrooms, bathrooms, laundry room, garage, side, and backyards. Food supplies were observed sufficient good for seven (7) days of non-perishables and two (2) days of perishables, and protected from contamination. Inside temperature was observed at 70 degrees Fahrenheit.

Facility has working carbon monoxide and smoke alarm detectors. Fire extinguisher checked, observed fully charged, and tag showed last serviced on 07/28/22. Facility maintains disaster drill records; fire drill conducted monthly and records. Hot water temperature in the common bathroom was tested and measured at 106.8 degrees Fahrenheit. First aid kit inspected and observed complete with manual.


Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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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: WOODBRIDGE HOME
FACILITY NUMBER: 079200361
VISIT DATE: 04/06/2023
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All indoor and outdoor passageways were free of obstructions. Disinfectants and cleaning solutions were locked and inaccessible to clients. All bedrooms were equipped with overhead lights, sufficient drawers, and beds with clean covers, mattress pads, and pillows. The toilet and bathing areas were observed safe and in operating condition. Cabinets in the kitchen where medications are centrally stored were locked. All staff were fingerprint cleared and associated to this facility.

Staff and clients' files were reviewed. Clients' cash resources records were checked. Medications and Centrally Stored Medication Records were inspected.

LPA received the following updated forms/documents on this day:
1. LIC308 Designation of Facility Responsibility.
2. LIC500 Personnel Report.
3. Copy of current administrator certificate (# 6044835735; expiration date: 7/18/2023).
4. LIC610D Emergency Disaster Plan.

No deficiencies cited during visit.

Exit interview conducted and a copy of the report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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