<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592947
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:26:19 PM


Document Has Been Signed on 01/30/2024 02:26 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 INCFACILITY NUMBER:
191592947
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:16409 WOODRUFF AVENUETELEPHONE:
(562) 925-6581
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:88CENSUS: 73DATE:
01/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Gemma Deoso - AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit for annual continuation. LPA met with Administrator, Gemma Deoso, who assisted with the inspection. The initial required-1 yr inspection was conducted on 01/29/2024. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools today for the remaining domains and observed the following:

Personnel Records-Training: Six (6) staff files were reviewed. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Administrator's certificate expired on 04/06/2023, but proof was presented to LPA showing that renewal was submitted in March 2023.Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted in the 1st floor hallway and by the main entrance. Per Administrator, facility provides internet services to all residents and have access to the facility phone.


Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted by the dining room. The facility has a Resident Council and council members/residents meet on a monthly basis.
Food Service: Sufficient food supply is stored in the kitchen and (2) pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: A total of eight (8) centrally stored resident medications were reviewed; containing 30-day supply of medications. LPA observed that the medications administered on 1/29/2024 to (1) resident (Resident #1/R1) were not properly documented/logged on the Medication Administration Record (MAR). A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided.
Resident Records/Incident Reports: A total of nine (9) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, Medication Records, and P & I Money Records. The Incident report binder was reviewed.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Eleven (11) residents are receiving home health services. Three (3) residents receive hospice care. Physician orders for postural support are on file. LPA observed half bed rails for mobility assistance in some resident beds. There are no residents with prohibited health conditions. Residents who are using oxygen have "No smoking In Use" signs posted on the residents doors.

Per California Code of Regulations, Title 22, deficiency was cited.

Exit interview conducted and a copy of the report and appeal rights were provided to Gemma Deoso, Administrator.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/30/2024 02:26 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the Administrator did not comply with the section cited above in which the medications administered on 1/29/2024 to Resident #1 (R1) were not properly documented/logged on the Medication Administration Record (MAR) which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
The Administrator agreed to submit a plan of correction to avoid medication errors focusing on the proper documentation of Medication Administration Record (MAR) to CCL/LPA by POC due date.
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.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2