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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592947
Report Date: 02/17/2022
Date Signed: 02/17/2022 12:27:00 PM


Document Has Been Signed on 02/17/2022 12:27 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



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: 64DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Receptionist Khrysta Margaros and
Administrator Chanel Sanchez 		TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Annual visit using the infection Control Evaluation Tool. LPA arrived unannounced and met with Receptionist Khrysta Margaros and Activity Coordinator Rosa Villalpando. The purpose of the inspection was discussed. The Administrator Chanel Sanchez , arrived shortly after to assist with the visit. During today's visit, LPA used the infection control tool to evaluate the facility. The facility is licensed for eighty eight (88) residents of which (20) can be ambulatory and (68) non ambulatory. The facility has a hospice waiver for eight (8) and currently has three (3) resident on hospice.

LPA and administrator toured the facility at 9:30 am. Areas inspected included but are not limited to: Dining room, activity room, TV room, common areas, eight (8) residents bedrooms - four (4) on each floor, kitchen, medication room. There are forty four (44) resident rooms. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways were free of obstruction. The outdoor activity area is free of visible hazards and debris. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit.

LPA toured randomly selected resident rooms. Rooms 108, 107, 117, 122 were inspected on the first floor, rooms 236, 239, 340, 242 were inspected on the second floor. All bedrooms were furnished with required furnitures. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested and measured within Title 22 Regulations guidelines. The emergency call light was tested on (3) rooms and was operating at the time of the visit. LPA observed the laundry room which contained 3 washers and 3 dryers. Activity room and TV room was also observed.

Continue 809C

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/17/2022
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The facility has a sprinkler system with wired alarm. Fire extinguishers are present through the facility and are fully charged. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods.

The hallways and stairways were inspected and were free of any obstructions. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed 6 resident files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the administrator.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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