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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:46:24 AM

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
08/22/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240822111712
FACILITY NAME:WOODRUFF CARE HOME INCFACILITY NUMBER:
191592947
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:16409 WOODRUFF AVENUETELEPHONE:
(562) 925-6581
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:88CENSUS: 80DATE:
08/29/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Khrysta Margaros - Assistant AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not obtain residents permission to change residents medical provider.
Staff financially abused resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPAs) Tena Herrera and Daniel Konishi conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPAs met with Jesus "Jessie" Chavez who allowed enterance to the office, shortly after Assistant Administrator Khrysta Margaros and Administrator Gemma Deoso arrived to assist, the reason for the visit was explained.

The investigation consisted of the following:
LPAs obtained copies of Resident and Staff Rosters and copies from Resident #1 (R1) file. LPAs interviewed 3 Staff, and LPA Konishi interviewed 8 residents.

(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
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-20240822111712
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: 08/29/2024
NARRATIVE
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The investigation revealed the following:
Allegation: Staff did not obtain residents permission to change residents medical provider.
It is alleged that staff dis-enrolled R1 from their primary care physician and made changes for R1 to have a new care provider without R1's consent. LPA Herrera reviewed R1's file and there were no indications that the provider was ever changed and the same provider appeared to be listed throughout R1's admission at facility. LPAs interviewed 3 staff, all of which denied the above allegation. Staff stated that they are are not authorized to make such changes and only residents have the authority to do so. Staff #2 (S2) stated that they will assist residents (if needed) when they are looking for care providers, however, only the residents are able to make the changes. All 3 staff stated that R1's care provider was the same from enrollment until their departure from facility. LPA Konishi interviewed 8 Residents and 8 out of 8 residents denied the above allegation, and stated that staff have never changed their health care provider at any point.
Allegation: Staff financially abused resident in care.
It is alleged that S3 stole $10 from R1 on 12/30/2023 for medications that R1 needed to pay a co-pay for. LPA Herrera reviewed R1's file and all fund deposits and withdrawals were documented and signed for by R1 on the Record of Resident's Safeguarded Cash Resources Form (LIC405). LPA also reviewed a Narrative Charting with the communication log between staff and R1 on reminders of funds needed to purchase medication, as there was a co-pay due, resident refused to pay for medication. LPAs interviewed 3 staff, all of which denied the above allegation. During interview with S3, staff stated that they have never stolen money from a resident, they do not handle resident funds and only administer medication. Interviews with S1 and S2 revealed that R1 was self responsible and handled their own funds, the only reason for the LIC405 was because R1 would write personal checks to facility for facility to exchange for cash, staff stated that they are the only staff with access to resident funds and document each time residents deposit/withdraw funds. Interviews with 3 staff also revealed that law enforcement investigated allegation, however, it was dismissed and no police report was generated. LPA Konishi interviewed 8 Residents, 6 out of 8 residents denied the above allegation, 2 out of 8 stated that they have lost belongings but have never had proof to report a stolen item/money as they have a foggy memory of what may have occurred.
Based on statements and interviews conducted with staff and residents, and review of R1's file, 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 held, and a copy of this report was provided to Administrator Gemma Deoso.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
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