191592947-10-21-2022-28-AS-JBAE-CKEURG-20221021154843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592947
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:48:57 PM

Document Has Been Signed on 10/21/2022 03:48 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	WOODRUFF CARE HOME INC		FACILITY NUMBER:	191592947
ADMINISTRATOR:	CARMEN GALICIA		FACILITY TYPE:	740
ADDRESS:	16409 WOODRUFF AVENUE		TELEPHONE:	(562) 925-6581
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	88	CENSUS: 56	DATE:	10/21/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:17 PM
MET WITH:	Administrator Carmen Galicia		TIME COMPLETED:	04:02 PM

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On 10/21/2022 at 1:27p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Case Management visit for an incident report and SOC341 received by CCLD on 10/10/2022. Carmen Galicia, Administrator faxed the Special Incident Report and SOC341 to the CCLD office as indicated on reporting requirements. Upon arrival LPA met S1 and explain the reason for the visit. At 1:37 Administrator Carmen Galicia arrived, and LPA explained the reason for the visit.

During the visit LPA toured the facility. LPA interviewed administrator, and Residents R1 through R3. LPA obtained a copy of staff roster, Resident roster, Incident report dated 10/10/22, SOC341 dated 10/11/2022, R1’s psychiatric evaluation dated 10/14/2022, R2’s psychiatric evaluation dated 10/14/2022, house rules, and S2 internal incident report.

Report continued on 809c

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODRUFF CARE HOME INC	FACILITY NUMBER: 191592947
	VISIT DATE: 10/21/2022

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The Special Incident Report indicates that the incident occurred on 10/08/2022 at approximately 10:10 am and involved a physical altercation between Resident #1 (R1) and Resident #2 (R2). According to the report R1 struck R2 with bare hands because R2 taunted R1. Interview with Administrator revealed there was a witness Resident #3(R3). LPA interviewed R3 to obtain more information. According to R3, R2 wanted a lighter, to which R1 asked R2 where was R2’s other Lighters. R2 then became verbally aggressive and threaten R1. R1 then proceeded to become agitated and walked closer to R2. R2 tried to kick R1 in the groin but missed and R1 then struck R2. Staff then proceeded to break up the altercation. Staff #2 (S2) was not available for interview, but per S2 internal incident report, S2 did not witness how the incident started but heard the residents arguing. S2 stated they saw R1 grab R2’s face and intervened to stop the confrontation. R1 stated that R2 was verbally aggressive and then R1 hit R2. R2 stated that they do not remember what happened during the altercation. R1 stated that they are getting along with R2. The administrator confirmed both residents was laughing together days after altercation. Psychiatric evaluation for R1 stated R1 is not a danger and is fine to stay in the facility. R2 is currently undergoing psychiatric evaluations. Per discussion with Administrator both residents will be given a warning as they broke house rule number #1 and the facility will create a plan of supervision for the residents during there smoke breaks.

During today’s visit, there were no deficiencies cited, per Title 22 regulations. Exit interview conducted and a copy of the report was given to Administrator Carmen Galicia during the exit interview.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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