191592947-1-30-2025-28-AS-THEA-DDEVS9-20250130154110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592947
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:41:58 PM

Document Has Been Signed on 01/30/2025 03:41 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/ DIRECTOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	16409 WOODRUFF AVENUE		TELEPHONE:	(562) 925-6581
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 88	TOTAL ENROLLED CHILDREN: 0	CENSUS: 83	DATE:	01/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Gemma Deoso - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Gemma Deoso and explained the purpose for today’s visit. The facility is licensed to serve 88 Residents ages 60 and over (20 Ambulatory / 68 Non-Ambulatory), with a Hospice waiver for 8 Residents. Facility currently has 83 residents (4 of which are receiving hospice services).

The Facility is a 2 story building located in Bellflower, CA. A tour of the facility included: 1st floor: Multiple resident rooms with private 1/2 bath or shared full bath (those without a bath are able to utilize restrooms throughout and a shower room), Activity Room, TV/Therapy Room, Kitchen, Dining Room, Laundry Room, Medication Room, Closets with storage throughout, and 2 outdoor activity/lounge area. 2nd floor: Multiple Resident Rooms with private 1/2 bath or shared full bath (those without a bath are able to utilize restrooms throughout and 2 common full bath/shower rooms).

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today:
Infection Control: Facility has sufficient PPE supplies and the required Infection Control Plan.
Operational Requirements: There is an approved fire clearance & facility has the required liability insurance.
Physical Plant & Environment Safety: LPA toured facility, multiple residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured below the required range of 105-120 degrees, citation will be issued with details on the LIC809-D page. There are shaded patio areas available for residents.
(Continued on LIC809-C)

David Sicairos	TELEPHONE: (323) 981-3982
Tena Herrera	TELEPHONE: 323-980-4633
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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: 01/30/2025

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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of

the residents in the case of an emergency.
Personnel Records-Training: Staff have criminal record clearance, current First-Aid/CPR/AED training along with other required training's documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator Gemma Deoso's Administrator Certificate expires on 4/6/2025.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 9 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone landline at the facility and the required posters such as, Residents Rights, Complaint Poster, and Ombudsman are posted throughout the facility..
Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. LPA reviewed 8 residents medications with no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 12/31/2024. Fire drills were being tested by Fire Alarm Company during visit and was observed to be operable.
Residents with Special Health Needs: Facility admits residents with hospice services and staff files reviewed today all have required training documented.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit will be cited on the 809D.

Exit interview held, a copy of the report and appeal rights will be emailed to Administrator Gemma Deoso at gdeoso@trucarecommunity.com

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2025 03:41 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as during tour along side of Administrator multiple resident restroom sinks and shower water temperatures were tested and observed to be below the required range of 105-120 degrees F, they had readings that ranged from 79.9-101.1 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/05/2025
	Plan of Correction
1 2 3 4	Administrator had maintenance adjust the water heater during visit. Administrator/Licensee to create a water temperature log and monitor water for the next 3 days (beginining 1/31/25, ending 2/2/25), water temperatrure is to be tested throughout facility and each measurement must be within the required range of 105-120 degrees F, water must be tested 3x a day (morning, afternoon, evening) and all must be documented on water temperature log to clear the POC. Water temperature log to be emailed to LPA by POC due date at tena.herrera@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

David Sicairos	TELEPHONE: (323) 981-3982
Tena Herrera	TELEPHONE: 323-980-4633
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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