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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 03/29/2021
Date Signed: 03/29/2021 04:47:35 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2020 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200916115944
FACILITY NAME:WOODRUFF CARE HOME INCFACILITY NUMBER:
191592947
ADMINISTRATOR:SANCHEZ, CHANELFACILITY TYPE:
740
ADDRESS:16409 WOODRUFF AVENUETELEPHONE:
(562) 925-6581
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:88CENSUS: 72DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Aurora Tecson, Assistant AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility has an infestation of bed bugs and cockroaches.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Aurora Tecson, the Assistant Administrator.

On 9/22/20, LPA Chan toured the facility with the Administrator using Facetime. LPA also interviewed the Administrator and Staff #1 - #4 (S1 - S4). LPA requested for copies of the Staff and Resident rosters with contact information, Pest Control Service contract including dates of recent services, and the house cleaning log. LPA Chan interviewed another staff on 12/11/20 and 8 residents on 1/7/21.

(Continue on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20200916115944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WOODRUFF CARE HOME INC
FACILITY NUMBER: 191592947
VISIT DATE: 03/29/2021
NARRATIVE
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In regards to allegation, Facility has an infestation of bed bugs and cockroaches. Based on interviews conducted on 9/22/20, the facility still has on-going issues with bed bugs and cockroaches. 4 out of the 8 residents interviewed indicated that they have seen cockroaches or heard others complain about the cockroaches at the facility. Witness #1 stated that bed bugs and cockroaches were seen at different times during his/her visits. The residents and witness #1 have seen baby cockroaches crawling in the room, at the edge of the bathroom door, and in the elevator. 2 of the staff interviewed on 9/22/20, also stated they observed cockroaches and/or bed bugs at the facility even though the rooms are cleaned thoroughly. They have indicated the cockroaches have been an on-going issue as they come out more often in the summertime.

Based on Admiral Pest Control service reports and agreement gathered, the facility upgraded pest control services from monthly to bi-weekly in September 2020 to service for general pest. The contract does not treat for bed bugs and is a separate service when needed. According to the interview with the Admiral Operations Manager on 3/4/21, the technician had recently encountered 8 rooms infested with bed bugs, with possibility that the bed bugs may be throughout the building. LPA obtained the Service Notification reports for 3/4/21 which stated that “an estimate for treatment of 8 rooms shown today with visible infestation was sent separately” for bed bugs. The report on 3/10/21 indicated that the 8 rooms were treated by Admiral Pest Control Company.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.



An exit Interview was conducted via telephone with the Assistant Administrator and a hardcopy was provided via email for signature. Appeal Rights was also provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200916115944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODRUFF CARE HOME INC
FACILITY NUMBER: 191592947
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Licensee shall provide proof of treatment of bed bugs and cockroaches and plan to prevent the pests from spreading in the facility. The proof shall be submitted to LPA Chan by POC due of 4/2/21.
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Based on interviews and documents reviewed, bed bugs and cockroaches were observed at different times, which poses a potential health and safety risk to residents in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3