191592947-3-4-2024-28-AS-LHIS-D3DMQJ-20240315094845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 03/04/2024
Date Signed: 03/04/2024 09:33:59 AM

Unsubstantiated

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
10/24/2023 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20231024150648

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:	DATE:	03/04/2024
		UNANNOUNCED	TIME BEGAN:	08:17 AM
MET WITH:	Administrator Gemma Deoso		TIME COMPLETED:	09:48 AM

ALLEGATION(S):

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Resident was physically assaulted while in care which resulted in injuries

INVESTIGATION FINDINGS:

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On 3/4/2024 at 8:17 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced follow up visit to this facility to deliver findings on the investigation conducted by Investigator / Sonia Sandoval. Upon arriving at the facility, LPA met with Med Tech who contacted the Administrator. At 8:45 a.m., the Administrator Gemma Deoso arrived, and LPA explained the reason for the visit.

Prior visits were conducted at this facility on 10/25/2023 in reference to the allegation listed above, consisting of a physical plant tour of the interior and exterior was conducted. During the tour LPA did not observe any health and safety concerns. LPA obtained the staff roster, resident roster, unusual incident report dated 10/25/2023 and 10/28/2023, SOC 341, and Inmate Information Center document dated 10/25/2023. LPA conducted file review and obtained all the following documents pertaining to R1: Basic fact sheet, Resident face sheet, Transfer discharge report, Medication administration record, Emergency and Identification Information, Physician’s Report, Discharge paperwork, and Resident assessment form. LPA obtained all the following documents pertaining to R2: Basic fact sheet, Identification and Emergency Information, Physician’s Report, Medication administration record, and Resident assessment form.
Report continued on 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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-20231024150648

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: 03/04/2024

NARRATIVE

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Based on interviews conducted and records reviewed, it was discovered that residents R1 and R2 were able to ambulate inside and outside the facility independently. Additionally, staff confirmed residents could be in the patio area unsupervised. The review of the surveillance footage revealed R1 assaulted R2 with an object (ashtray pole) on 10/21/2023 at 0851 hours. The review of the EMS and 911 audio all revealed Los Angeles County Fire Department was dispatched to the facility at 0859 hours, approximately eight minutes after the incident. The facility staff interviewed revealed R1 had not displayed aggressive behavior towards staff/residents and had no prior incidents. The interview of facility staff confirmed R2 and R1 were separated and assessed. Emergency medical services were requested, and law enforcement was notified of the incident.
Based on interviews, and file review the investigation revealed: 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 conducted with Gemma Deoso and a copy of this record provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC9099 (FAS) - (06/04)

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