191592947-2-16-2023-28-AS-TVAO-CPJPUQ-20230302103754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:06:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/17/2021 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211117125615

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: 57	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Administrator Carmen Galicia		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not provide timely medical attention to resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Kimberly Ramirez and LPA Tena Herrera conducted an announced subsequent complaint visit stemming from initial complaint visit dated 11/22/2021. LPA’s met with Administrator Carmen Galicia and explained the purpose of the visit.

The investigation consisted of the following: A physical plant inspection of the facility was conducted at 10:02 am. Staff (S1-S5) and residents (R1-R4). LPA’s requested a copy of LIC 500, resident roster, Resident R1 face sheet, R1 Emergency contact sheet, R1 Physician orders, R1 medical records, LIC 624, Post Discharge Plan of Care and Outside Agency Documentation log.

See LIC 9099-C for continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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-20211117125615

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODRUFF CARE HOME INC	FACILITY NUMBER: 191592947
	VISIT DATE: 02/16/2023

NARRATIVE

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Allegation: Staff did not provide timely medical attention to resident. It is alleged that R1 was observed with a mass on her eye with maggots. Staff (S1 – S5) all deny this allegation. S1 stated they assist residents with all medical needs and try their best to arrive to assist in a timely manner. R2 stated when he/she needs assistance, staff arrives quick and assist him/her. R1 was not available for an interview and has since passed away. Review of R1’s Outside Agency Documentation log, shows a wound care specialist was arriving to the facility once a week from 10/01/2021 to 11/15/2021 to provide wound care. S1 -S4 all acknowledge that R1 would refuse medical treatment and would require coaching to allow staff to groom R1. R2 confirmed that R1 would refuse medical treatment for wound care. LIC 624 dated 11/16/2021 indicates R1 was sent by non-emergency ambulance to Norwalk Community Hospital for treatment of wound to left eye.

Based upon records review and interviews conducted, and observations made the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was held with Administrator Carmen Galicia. A copy of this report was issued

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

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