191592947-9-28-2023-28-AS-DSIS-CWGS5R-20231010133447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 09/28/2023
Date Signed: 09/28/2023 04:35:25 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
09/19/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230919114700

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: 71	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Gemma Deoso - Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not administer resident's medication as prescribed.
Staff did not provide adequate food service.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to
investigate the allegations listed above. LPA met with Gemma Deoso, Administrator and explained the reason for the visit.
The investigation consisted of the following: LPA obtained copies of Resident & Staff Rosters, weekly menus (Sep 2023), Resident #1 (R1) files such as; AdmissionAgreement, Physician's report, Identification and Emergency Information, Preplacement Appraisal and Appraisal, Special Incident Reports (dated 2/12/2023 & 8/29/2023), Medication list, Medication Administration Record (MARs) for Jul 2023-Sep 2023, Hospital's discharge papers for R1and letter from R1’s physician stating she can manage her own meds. At 12:30pm, LPA conducted a tour of the facility’s common areas, focusing on the kitchen and dining area. LPA observed that the dining area was closed due to the facility under quarantine. However, LPA observed the food served during lunch consisted of whole grains, nuts, fruit and vegetables. At 1:20pm, LPA reviewed R1’s medication list and MARs. Between 1:40pm-2:45pm, LPA interviewed Staff #1 (S1) - Staff #7 (S7), and between 2:45pm-3:45pm, LPA interviewed Resident #1 (R1) – Resident #9 (R9). *****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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-20230919114700

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: 09/28/2023

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: " Staff did not administer resident's medication as prescribed.” It is alleged that the facility staff have been mismanaging R1's medication and that the staff are failing to administer it in a timely manner. Facility staff interviewed denied the allegation. Staff stated that resident #1 is medication compliant and staff follow R1's medication directions. Staff stated that R1 is not capable of managing her own medication and being assisted by staff. S3 stated that she received the letter provided by R1 regarding medication administration, however, the letter was incomplete. S3 stated that facility has not received the updated letter that they requested from R1's physician. LPA reviewed Resident #1's medication list and Medication Administration Record (MAR) for Aug-Sep. 2023, and observed that R1's medication has been administered as prescribed. LPA also reviewed R1's Physician's report which stated that R1 is not capable of managing her own medication. (8) out of (9) residents interviewed were unable to corroborate the allegation. Other residents interviewed stated that they are receiving their medication as prescribed and do not have any problems.

In regards to the allegation: "Staff did not provide adequate food service.” It is alleged that the staff are failing to provide adequate food service, that on 09/18/2023 R1 did not get any food for dinner. Staff interviewed denied the allegation and stated that residents get their regular meals 3x a day plus snack. And if residents request extra meal, they get it. Staff interviewed also indicated that a resident can easily use the call light in their rooms if they need assistance, whether it's ordering food or other requests. At 12:30PM, LPA conducted a tour of the kitchen and dining area and observed adequate amount of food prepared and packed for lunch. The food was prepared by the cook and the kitchen worker was ready to deliver the food trays (wrapped) to the rooms. Currently, the facility is under quarantine and meals are being delivered to the residents room. The meal included fruit, vegetables, nuts and whole grains. Some meals were labeled to serve residents with dietary preferences. The food is observed to be adequate and sufficient to meet the residents’ nutritional needs. LPA obtained a copy of the weekly menu for the month of Sep. 2023. The menu included different items from each food group and listed alternatives, including snacks on the menu. (8) out of (9) residents interviewed stated that the staff had never missed providing them meals and they do not have problems with the meals being served to them. Other residents stated that they get their meals 3x/day plus snacks. Some residents indicated that they can call a staff by using the call light in their rooms if they want extra food or an alternate menu. LPA also observed the Local Ombudsman contact information posted on the wall in the hallway, next to the elevator and the front office, which was visible to residents in the facility.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview, a copy of this report was provided to the Facility Administrator, Gemma Deoso.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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