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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200609
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:18:44 PM

Document Has Been Signed on 12/09/2021 02:18 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:WOODBRIDGE CLAYTONFACILITY NUMBER:
079200609
ADMINISTRATOR:MUTYA, JOHANNAFACILITY TYPE:
734
ADDRESS:8001 KELOK WAYTELEPHONE:
(925) 673-5442
CITY:CLAYTONSTATE: CAZIP CODE:
94517
CAPACITY: 4CENSUS: 3DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jennfer Mose (interim Adminsitrator) & Melizza Cortez (Administrator)TIME COMPLETED:
02:50 PM
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On 12/9/2021, Licensing Program Analyst (LPA) L. Ibo conducted a health and safety check as a result of department receiving a priority 1 complaint. LPA met with staff Jennifer Mose who is the interim Administrator; LPA explained the purpose of the visit. At 12:30PM Administrator Melizza Cortez arrived at the facility.

During the health and safety check, LPA toured the facility with staff Jennifer Mose, LPA toured inside and outside of the facility including but not limited to common areas, bathrooms, bedrooms and outdoor area. LPA observed smoke detectors and carbon monoxide detector throughout facility.

Residents in care appear to be safe . LPA observed lunch was being served with the residents during visit. Facility is maintained at a comfortable temperature for the residents in care. Facility has enough PPE supplies & food supplies. According to Jennifer M. staff were N95 fit tested and new staff are currently scheduled for fit testing.

...Continued to LIC808C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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 CLAYTON
FACILITY NUMBER: 079200609
VISIT DATE: 12/09/2021
NARRATIVE
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LPA observed the following:

One staff (S2) was observed working with residents in care, S2 has pending fingerprint exemption clearance. LPA informed Administrator via phone call that S2 need to leave the facility as soon as possible. S2 left the facility after S4 arrived at the facility which was 11:00AM.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.



$500.00 Civil penalty was assessed.

Deficiencies and plan and proof of corrections were discussed with Melizza Cortez.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2021 02:18 PM - It Cannot Be Edited


Created By: Leslie Ibo On 12/09/2021 at 12:52 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: WOODBRIDGE CLAYTON
FACILITY NUMBER: 079200609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2021
Section Cited
CCR
80019(e)(1)

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Criminal Record Clearance
Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement is not met as evidence by:
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Administrator will provide documents for S2's fingerprint process to CCLD by 12/10/2021. Administrator will also submit a statement regarding future staff will be cleared prior to working at the facility.
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Based on investigation, licensee did not comply with the section cited above by having staff who are not cleared work at the facility which poses an immediate health and safety risk to the clients in care.
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Civil penalty of $500.00 is being assessed.

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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: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


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