191592947-3-14-2023-28-AS-NGAA-CPX2DS-20230314171850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592947
Report Date: 03/14/2023
Date Signed: 03/14/2023 05:19:54 PM

Document Has Been Signed on 03/14/2023 05:19 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: 58	DATE:	03/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Carmen Galicia, Administrator		TIME COMPLETED:	05:20 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Carmen Galicia. There are currently 58 elderly residents 60 years and older residing in the facility. One resident (1) is receiving hospice care.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. Room # 232 is designated as a COVID-19 isolation room if needed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

Operational Requirements:

A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.
The facility does not have a Dementia Waiver in place. A Hospice Waiver for 8 is approved.
A fire clearance for 20 ambulatory and 68 non-ambulatory residents is in place.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 1/1/2024.
Surety bond of $10,000.00 is current.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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: 03/14/2023

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Physical Plant/Environment Safety:

The facility is a 2-story building located that is licensed for 88 elderly residents ages 60 and older. It consists of 45 resident rooms, 2 administrative offices, medication room, kitchen, dining room, caregiver room, 2 shower rooms janitor rooms, laundry room, electrical room, boiler room, 2 courtyards, and an activity patio located in the rear of the property.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.
On 9/27/2022 LA County Fire Department conducted a fire inspection. Fire clearance was denied pending corrections. Corrections were submitted on 11/4/2022, but facility has not obtained fire clearance verification. A call was placed during this visit. The fire inspector did not return the phone call.
On 10/16/2022, R4 Fire Testing Services Inc. conducted an inspection to correct the violations identified in the Fire Department report. The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The facility has eight (8) fully charged fire extinguishers.
Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 101.6 - 109.9 degrees Fahrenheit. Maintenance staff cleaned the boiler during the inspection. However, circulation pumps need replacement.
Rooms 108, 112, 127, 233, and 239 were missing window vertical blinds. Room 242's floors were dirty.
Rooms 109 & 112 did not have Oxygen posters on the door. Signs were posted during the visit.

Staffing:

A total of 32 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificates expires 12/3/2023.
Staff have criminal background clearance and training.
Five (5) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training are current.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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: 03/14/2023

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Resident Records/Incident Reports:

A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records.
RCFE complaint poster and Personal rights were observed posted in the 1st floor hallway. The Incident report binder was reviewed.

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar is posted by the dining room.
The facility has a Resident Council.

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
Physician orders for modified diets are on file.
Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:

Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications.
Medical and dental transportation is provided.

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place.
Records of resident Appraisal and Needs services plans are part of Emergency training.

See next page

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2023 05:19 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87618(b)(3)(B)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that Rooms 109 and 112 did not have "No Smoking In Use" signs on the door; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2023
	Plan of Correction
1 2 3 4	Staff posted signs on the doors during the visit. CLEARED.

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that rooms 119, 123, 126, 127, 233 had hot water temperatures that were below 105 degrees Fahrenheit; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit proof of correction by tomorrow. Maintenance staff stated that circulation pumps are in need of repair.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2023 05:19 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the last emergency drill was conducted on 1/13/2022; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit proof of emergency drill training.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation 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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that rooms 108, 112, 127, 233, and 239 were missing window vertical blinds, and Room 242's floors were dirty. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit picture proof evidence that the room windows have complete vertical blind panels, and that room 242 has been cleaned.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: 03/14/2023

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Residents with Special Health Needs:

Nine (9) residents are receiving home health services. One (1) resident receives hospice care.
Postural support physician orders are on file.
Half bed rails for mobility assistance were observed in some resident beds.
Individual Service Plans and Appraisals are on file.
No residents have prohibited health conditions.
"No smoking In Use" signs were not posted on the resident doors.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Carmen Galicia. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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