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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 10/13/2021
Date Signed: 10/13/2021 11:19:37 AM



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
10/04/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211004120039
FACILITY NAME:WOODRUFF CARE HOME INCFACILITY NUMBER:
191592947
ADMINISTRATOR:SANCHEZ, CHANELFACILITY TYPE:
740
ADDRESS:16409 WOODRUFF AVENUETELEPHONE:
(562) 925-6581
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:88CENSUS: 66DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Chanel Sanchez TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility has lice.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a unannounced complaint visit to address the above allegation. LPA met with Administrator, Chanel Sanchez and explained the reason for the visit.

The investigation consisted of the following: On today's visit, LPA interviewed five staff (S1-S5), six residents (R2-R6). LPA also reviewed Resident#1 (R1)'s file and obtained copy of staff and resident roster, R1's face sheet and physician report.

The investigation revelaled of the following: Allegation: "Facility has lice". LPA interviewed six (6) residents and four residents reported the facility has lice. They reported they either knew some residents had it or they are currently on the head lice treatment now. LPA interviewed five staff and all reported some residents had head lice and some of them are in the treatment now or they already had finished the head lice treatment.

(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20211004120039
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: 10/13/2021
NARRATIVE
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Based on LPA’s interviews which were conducted, the preponderance of evidences standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of the report and the appeal rights were given to the administrator Chanel Sanchez
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20211004120039
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: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Right of Residents in All facilities. (a)(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment The requirement is not met as evidenced by
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The administrator will ensure residents to be accorded safe and healthful and comfortable accomendations..etc. The administrator will send a plan to LPA about how to prevent head lice in the facility by POC due date.
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LPA's interviews and recorded review, four out of six residents reported that facility has head lice, either they heard about it or either they are on lice treatment now. Staff also reported facilty has head lice and residents are on treatment now which posed a potential risk to residents in care.
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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 YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3