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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201198
Report Date: 08/20/2024
Date Signed: 08/20/2024 05:05:47 PM

Document Has Been Signed on 08/20/2024 05:05 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:SOUTHWOOD SENIOR LIVING, LLCFACILITY NUMBER:
079201198
ADMINISTRATOR/
DIRECTOR:		VILLANUEVA, VELBAFACILITY TYPE:
740
ADDRESS:2073 SOUTHWOOD DRIVETELEPHONE:
(415) 509-1667
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 4CENSUS: 1DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:MARIAZITA JARDELEZA, CAREGIVERTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On 08/20/2024 at 1:20PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Mariazita Jardeleza and explained the purpose of the visit. Velba Villanueva, Administrator arrived at 2:50pm, the Administrator currently holds a certificate (#6024026740) that expired on 05/18/2024. The facility’s fire clearance was approved for four (4) non-ambulatory residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of three (3) total bedrooms which one (1) bedroom is occupied by staff. No bodies of water observed. A comfortable temperature is maintained in the home. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 05/04/2022. First aid kit was observed to be complete.

Continued on LIC809.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 08/20/2024 05:05 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/20/2024 at 03:58 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: SOUTHWOOD SENIOR LIVING, LLC
FACILITY NUMBER: 079201198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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
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Based on observation, the licensee did not comply with the section cited above in Windex, Ajax, Fabuloso in the bathroom cabinet and Cascade and Ajax in the kitchen cabinet and the knife drawer unlocked which poses an immediate health and safety to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Administrator agreed to read and understand the regulation and conduct an in-service with staff and provide the Department with a photo of cabinets with locks or items removed along with a signing sheet of staff attended by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2024 05:05 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/20/2024 at 03:58 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: SOUTHWOOD SENIOR LIVING, LLC
FACILITY NUMBER: 079201198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

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 in having 5 unlocked storage doors unlocked, 3 ladders, paint, large tool box unlocked with tools, electric saw, wood planks, pick hoe garden tool, 3 shovels, wheelbarrow, and 3 scooters, located in the open porche area which poses potential health and safety risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator agreed to remove the 3 ladders, paint, large tool box unlocked with tools, electric saw, wood planks, pick hoe garden tool, 3 shovels, wheelbarrow, and 3 scooters, lock all storage doors and submit pictures to the Department by the POC date.
Type B
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the fire extinguisher has an expired date which posed a potential Health & Safety risk to residents in care.
POC Due Date: 08/23/2024
Plan of Correction
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Administrator agreed to have Fire extinguisher serviced or purchase another one and submit photos of the new tag or receipt to the Department 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


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: SOUTHWOOD SENIOR LIVING, LLC
FACILITY NUMBER: 079201198
VISIT DATE: 08/20/2024
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Continued from LIC809.

LPA reviewed three (3) staff files all are complete. One (1) resident file was reviewed and complete.

LPA observed the following deficiencies:
  • At 2:00pm, LPA observed cleaning solutions Windex, Ajax, Fabuloso in the bathroom cabinet and Cascade and Ajax in the kitchen cabinet unlocked.
  • At 2:07pm, LPA observed the fire extinguisher was expired.

  • At 2:20pm, LPA observed 5 unlocked storage doors unlocked, 3 ladders, paint, large tool box unlocked with tools, electric saw, wood planks, pick hoe garden tool, 3 shovels, wheelbarrow, and 3 scooters, located in the open porche area

LPA requested the following documents to be submitted to CCLD by 09/10/2024.
  • Resident Roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Copy of Administrator Certificate


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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