191592947-1-8-2024-28-AS-TVAO-CZJQDK-20240116110449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 01/08/2024
Date Signed: 01/08/2024 02:30:33 PM

Substantiated

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
09/12/2022 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220912122555

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: 73	DATE:	01/08/2024
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Khrysta Margaros-Assistant Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility has bed bugs throughout the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit on 01/08/2024 and delivered findings. LPA Ramirez was met by Khrystal Margaros- Assistant Administrator and explained the purpose of the visit.

The investigation consisted of the following: Initial complaint investigation was conducted on 09/21/2022 by LPA Mora. LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 interviews (S1-S4), Resident #1- 6 interviews (R1 – R6), Resident#7 (R7): Face sheet, Admissions Agreement, Physician Report dated 02/10/2022, Special Incident Report (SIR) dated 07/13/2022 & 09/30/2022, Facility menu for the week of 01/07/2024 through 01/13/2024, Facility Meal Entrée Alternative Policy, List of diabetic residents, List of residents with dietary restrictions, List of facility sugar free items available to residents, Orkin Pest Control Service reports dated 10/25/2023 and 12/19/2023 and physical plant tour.
SEE 9099-C for continuation of report.

Substantiated

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: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20220912122555

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: 01/08/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegation: Facility has bed bugs- It is alleged the facility has bed bugs. LPA Ramirez toured six (6) resident rooms. Two (2) out of four (4) staff interviewed confirmed this allegation. Five (5) out of the six (6) residents interviewed confirm this allegation. LPA Ramirez observed several brownish-red stains throughout R6’s pillowcase. LPA Ramirez observed Orkin Pest Control service reports dated 10/25/2023 and 12/19/2023, that indicated the facility was treated for bed bugs. Based on observations, records review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Deficiency is being cited. Exit interview was conducted and a copy of this report, 9099-D and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20220912122555

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/08/2024 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 was not met as evidence by:	1 2 3 4 5 6 7	*Facility provided proof of pest control service report dated 12/19/2023 for bed bug treatment. No further action required. Administrator advised LPA Ramirez that the facility is in the process of conducting a revised pest control proposal. Licensee will submit to LPA once received.
	8 9 10 11 12 13 14	Based on observations, interviews and records reviewed, the facility was being treated for bed bugs on 10/25/2023 and 12/19/2023.	8 9 10 11 12 13 14
	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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
09/12/2022 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220912122555

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: 67	DATE:	01/08/2024
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Khrysta Margaros-Assistant Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff exposed resident to hazardous materials.
Staff did not accord dignity to a resident in their relationship.
Staff do not serve palatable meals.
Staff do not serve alternative foods for diabetic resident.

INVESTIGATION FINDINGS:

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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: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20220912122555

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: 01/08/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegation: Staff exposed resident to hazardous materials- It is alleged staff sprayed insect spray while resident# 7 (R7) was present. Four (4) out of the four (4) staff interviewed deny this allegation. Six (6) out of the six (6) residents interviewed deny this allegation. Due to R7 no longer being in the facility, LPA Ramirez was unable to interview resident or contact resident. LPA Ramirez conducted physical plant tour and did not observe and hazardous materials accessible to residents in care. 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 allegation is UNSUBSTANTIATED.
Staff did not accord dignity to a resident in their relationship- It is alleged facility did not treat R7 with dignity and accused R7 of brining insects into the facility. Four (4) out of the four (4) staff interviewed deny this allegation. Six (6) out of the six (6) residents interviewed deny this allegation. Due to R7 no longer being in the facility, LPA Ramirez was unable to interview resident or contact resident. LPA Ramirez observed several staff providing care and supervision. LPA Ramirez did not observe any deficiencies. 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 allegation is UNSUBSTANTIATED.
Staff do not serve palatable meals- It is alleged the facility is not serving palatable meals to diabetic residents. Four (4) out of the four (4) staff interviewed deny this allegation. Three (3) out of the six (6) residents interviewed revealed that sometimes meals provided by the facility are lacking flavor. Due to R7 no longer being in the facility, LPA Ramirez was unable to interview resident or contact resident. LPA Ramirez toured kitchen while lunch was being prepared. LPA Ramirez observed various spices and seasonings in facility pantry. LPA Ramirez observed facility menu near kitchen entry. LPA Ramirez did not observe and deficiencies in kitchen area. 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 allegation is UNSUBSTANTIATED.
Staff do not serve alternative foods for diabetic resident. It is alleged the facility does not serve alternative foods for diabetic residents. Four (4) out of the four (4) staff interviewed deny this allegation. Six (6) out of the six (6) residents interviewed deny this allegation. Due to R7 no longer being in the facility, LPA Ramirez was unable to interview resident or contact resident. LPA Ramirez observed facility’s alternate entrée policy near kitchen entrance. Interviews with staff revealed that residents with diabetic restrictions or other dietary restrictions may choose items from this menu. LPA Ramirez observed “Diabetic Residents List” in kitchen area where kitchen staff prepare meals for residents. LPA Ramirez observed sugar-free condiments and food items in facility pantry. 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 allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC9099 (FAS) - (06/04)

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