191592947-12-12-2022-28-AS-MVAO-CMJPT8-20221228103531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 12/12/2022
Date Signed: 12/12/2022 12:08:15 PM

Unsubstantiated

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
04/21/2020 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200421112512

FACILITY NAME:	WOODRUFF CARE HOME INC		FACILITY NUMBER:	191592947
ADMINISTRATOR:	SANCHEZ, CHANEL		FACILITY TYPE:	740
ADDRESS:	16409 WOODRUFF AVENUE		TELEPHONE:	(562) 925-6581
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	88	CENSUS: 58	DATE:	12/12/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Carmen Galicia- Adminstrator		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Resident's behavior poses as a risk while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent complaint visit at the facility for the purpose of investigating the above mentioned allegation. LPA Maldonado met with Administrator Carmen Galicia and explained the purpose for the visit.

On 04/27/20 at 8:48 AM the LPA Arterberry interviewed a resident who shall be referred to as R1. On 04/27/2020 at 11:25 AM the LPA also interviewed the administrator. The following documents were supplied by the administrator for R1: Woodruff Care Home Identification Page/Face Sheet, 30-Day Notice of Eviction dated 03/31/2020, House Rules, Psychiatric Progress Notes dated 04/20/2020, Individualized Service Plan (ISP), Resident Assessment Form, Lakewood Regional Medical Center Discharge Instructions and Unusual Incident Reports (SIR).

(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200421112512

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: 12/12/2022

NARRATIVE

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During today's visit, LPA Maldonado requested a copy of the resident/staff roster and a copy of the previously requested documents for review- these documents were not available for review prior to this visit.

The investigation revealed the following:

Regarding allegation- Resident's behavior poses as a risk while in care.
It is alleged that the behaviors of R1 pose a risk while in care due to R1 drinking to excess and not adhering to house rules. This caused R1 to become aggressive to the point of police being called on 04/14/2020. Per R1's ISP and Resident Assessment, R1's level of awareness consists of frequent agitation, aggressiveness by using foul language and threatening, depression, and hallucinations/delusions. After review of the hospital discharge documents for R1, it was discovered that R1 was admitted to the hospital on 4/14/20 due to acute alcohol intoxication. Facility staff assisted resident in trying to de-escalate the situation and took action by calling 911. Then, a final eviction notice was issued to R1 on 03/31/20, for non-compliance with the house rules.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the complaint investigation of the allegation is unsubstantiated.

Per California Code of Regulations, Title 22, no deficiencies will be cited.

An exit interview was conducted with administrator Carmen Galicia and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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