191592947-7-1-2021-28-AS-FFIS-C72TC5-20210920143609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 07/01/2021
Date Signed: 07/01/2021 04:28:56 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
06/23/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210623114937

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: 71	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	12:59 PM
MET WITH:	Grace Baron - Wellness Director		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility is infested with bedbugs

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation due to the above allegation. LPA Flores met with and explained the reason for the visit. Assistant Administrator Aurora Tecson arrived an hour later.

The investigation consisted of the following: LPA Flores conducted a tour of the facility and observed randomly choosen rooms # 233, 234, 236, 241, 122, 133, 110, 108. LPA Flores interviewed residents #1(R1), #2(R2), #3(R3), #4(R4), #5(R5), #6(R6), #7(R7), #8(R8) and staff #1(S1), #2(S2), #3(S3), #4(S4), #5(S5), #6(S6). LPA requested a copy of staff and resident roster and assisstant administrator provided copies of pest control services for the facility for the months of April, May, and June.

The investigation revealed the following: Regarding allegation; Facility is infested with bedbugs. It is alleged resident had live bedbugs on resident's person, at least 5 bedbugs were killed. During the facility's tour LPA obseved a roach in room # 236 and #108. Beds in room #110 had blood small blood stains in mattress cover around the zipper area and a small bed bug in room #133. During interviews with residents, 4 out of 7 residents stated not to have observed bed bugs, (CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

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-20210623114937

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: 07/01/2021

NARRATIVE

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but have observed either termites or roaches,1 out of the 4 stated to have bites in arm. 3 out of 7 residents stated to have had bed bugs but had not seen any since facility began treatment. Interviews with staff revealed, 5 out of 6 staff stated to have observed bed bugs in residents room or bedding and has lessen upon treatment. 1 out of 6 staff stated to have not observed any bed bugs or roaches in the facility. Assistant administrator stated facility has had a bed bug issue and facility is currently going under treatment with pest control company. Documents reviewed revealed Round the Clock Pest Control provided bed bug treatment on 5/20/21, 6/3/21, 6/10/21, 6/16,21, 6/23/21 and roach treatment on 6/28/21.

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

Exit interview was conducted with Aurora Tecson assistant administrator and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210623114937

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: 07/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/15/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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 evidence by:	1 2 3 4 5 6 7	Licensee will continue to provide pest control services, will certify with LIC 9098 of continous treatment, and submit invoice of current services by 7/15/21 to the department.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

LIC9099 (FAS) - (06/04)

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