191592947-1-29-2024-28-AS-BPEA-CZXVBD-20240129151721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592947
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:17:53 PM

Document Has Been Signed on 01/29/2024 03:17 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	WOODRUFF CARE HOME INC		FACILITY NUMBER:	191592947
ADMINISTRATOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	16409 WOODRUFF AVENUE		TELEPHONE:	(562) 925-6581
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	88	CENSUS: 73	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Gemma Deoso - Administrator		TIME COMPLETED:	03:26 PM

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Administrator Gemma Deoso and explained the purposed of the visit. There are currently (73) residents, 60 years and older residing in the facility, of which (5) are bedridden and (3) are under hospice care.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

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. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date.

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. Facility is approved for (8) hospice residents. 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 03/01/2024. Surety bond of $10,000.00 is current. Fire drill is conducted on a quarterly basis and a simulated fire drill was last conducted on 01/19/2024.

Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: Lobby, Administrative offices, Medication room, Laundry room, (1) Elevator, Large Dining area, Kitchen, 2 Pantries, Activity patio, TV room, Storage room, Boiler room, (2) enclosed Patios by the main entrance, (2) Courtyard areas, Backyard patio/smoking area, and (30) resident bedrooms. Second floor: (18) resident bedrooms, Electrical room, Break room, (2) bathrooms with shower. 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. Between 11:00am-12noon, LPA tested hot water temperature in twelve (12) random resident rooms (Rooms #104, #106, #107, #118, #119, #121, #232, #235, #238, #240, #242 and #245) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has eight (8) fully charged fire extinguishers, last serviced on 11/20/2023.

*****CONTINUED ON LIC809-C*****

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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
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: 01/29/2024

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Staffing: A total of (31) staff members provide care and supervision to the residents, including the Administrator. LPA reviewed a total of (6) staff files. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate expired on 04/06/2023, but proof was presented showing that renewal was submitted in March 2023.

Personnel Records-Training:

Resident Rights-Information:

Planned Activities:

Food Service:

Incident Medical and Dental:

Resident Records/Incident Reports:

Disaster Preparedness:

Residents with Special Health Needs:

Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection.

Exit interview conducted with Gemma Deoso, Administrator and a copy of this report has been provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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