191592947-8-20-2021-28-AS-MVAO-C74R5F-20210922124303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 08/20/2021
Date Signed: 08/20/2021 01:00:16 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
08/16/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210816084316

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: 66	DATE:	08/20/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Assistant Administrator, Aurora Tecson		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff did not ensure facility was free from cockroaches

INVESTIGATION FINDINGS:

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Licensing Program Analyst's (LPA's) Linda Almaraz and Luis Mora conducted a complaint visit to investigate the allegations listed above. LPA met with Office Assistant, Margarette Cartera and discussed the reason for todays visit. Later during the visit, Assistant Administrator Aurora Tecson arrived.

The investigation consisted of the following: LPA requested staff and resident roster, and collected Pest Control records. LPA conducted interviews with Cartera, Tecson, Staff #1 and Residents # 1-10.

The investigation revealed the following: Interviews conducted with residents revealed the facility has a on going issue with cockroaches at the facility. Eight (8) out of Ten (10) residents stated they have seen roaches in their rooms and in their drawers. Interviews with staff revealed although the facility has cockroaches they have been receiving treatments from the pest control company. Records reviewed revealed the facility has had a cockroach issue since last year. (Continued on an LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

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-20210816084316

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: 08/20/2021

NARRATIVE

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Pest control records indicated the facility was on a monthly treatment last year and started doing every other week treatments for cockroaches for the past 2 months. Invoice records indicated the resident rooms are not being treated for cockroaches and only common areas are being treated. During the facility walk-through, LPA's saw a live cockroach in pantry #2 and seen several dead roaches in residents rooms and kitchen.

Based on interviews conducted, observation and records review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. This is a repeated citation from 3/29/2021. Civil Penalties assessed.

An exit Interview was conducted with the Assistant Administrator and a hardcopy was provided. Appeal Rights was also provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210816084316

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: 08/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/03/2021 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 evidenced by:	1 2 3 4 5 6 7	Administrator will increase the frequency of treatments to weekly and will treat the whole facility, including resident rooms, for cockroaches to eradicate the issue. Administrator is cleaning the facility next week and will be using a large bin to discard all unnecessary trash and infested furniture.
	8 9 10 11 12 13 14	Based on interviews and documents reviewed, the facility continues to have issues with cockroaches at the facility despite receiving treatments every other week which poses a potential health and safety risk to residents incare.	8 9 10 11 12 13 14	Administrator will email new contract with pest control company by POC due date.
	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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

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