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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191592947
Report Date: 12/09/2021
Date Signed: 12/09/2021 01:50:01 PM



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
12/06/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211206123535
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: 65DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Chanel Sanchez TIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident left in soiled diapers
Residents bed linins are not being changed timely
Residents personal belongings are missing
Staff are not answer residents call button timely
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted an unnnounced complaint visit to the above facility and investigateed the abvoe allegations. LPA met with Janitor- Reynaldo Apostol and explained the reason of the visit. At around 9:20am, the adminsitrator Chanel Sanchez arrived and assisted with the visit.

The investigation consisted of the following: On today's visit, LPA interviewed seven (7) residents, administrator and four (4) staff. LPA also obtained copy of documents for Resident#1 and #2 (R1 and R2)

The investgiation revealed of the following: Allegation#1 "Resident left in soiled diapers." LPA interviewed seven (7) residents and five residents reported they never left in soiled diapers. The caregiver usually come regularly to change them or residents would use the call light/call button and ask the caregivers to change them if needed. LPA interviewed staff and staff denied the allegation and reported they never left residents in soiled diapers from a long time. They always tried to keep them clean and dry.
(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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 5
Control Number 28-AS-20211206123535
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: 12/09/2021
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
26
27
28
29
30
31
32
Allegation#2 "Residents bed linins are not being changed timely" LPA interviewed seven (7) residents and five (5) residents reported the staff usually changed their bed linen daily or every two to three days. The bed linens are always clean. LPA interviewed staff and denied the allegation and reported they usually changed residents' bed linens depends on their daily condition but for regular base, the residents' bed linens usually changed once or twice weekly.

Allegation#3 "Residents personal belongings are missing" LPA interviewed seven (7) residents and five (5) residents reported they never lost anything in the facility. They all feel safe living in the facility. LPA asked staff and reported they usually would assist resident to locate the missing items or sometimes residents belongings are still in their bedroom or laundry bag which they did not recognize.

Allegation#4 "Staff are not answer residents call button timely." LPA interviewed seven (7) residents and six (6) residents reported that the caregiver always answered the call light/call button in a timely manner. The longest time that the caregiver would usually take about ten minutes. They do not have any issues with the call button/call light. LPA interviewed staff and denied the allegation. The staff usually responded the call button right away. The administrator reported if the caregivers are busy with the residents, other staff in the facility would step in and help out too.

Based upon interviews conducted, record review, and observations made the findings indicate that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Administrator Chanel Sanchez. A copy of the report was provided.

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/06/2021 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20211206123535

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: 65DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Chanel Sanchez TIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not following physicians orders to check blood pressure/ blood sugar
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted an unnnounced complaint visit to the above facility and investigateed the abvoe allegation. LPA met with Janitor-Reynaldo Apostol and explained the reason of the visit. At around 9:20am, the adminsitrator Chanel Sanchez arrived and assisted with the visit.

The investigation consisted of the following: On today's visit, LPA interviewed seven (7) residents, administrator and four (4) staff. LPA also obtained copy of documents for Resident#1 and #2 (R1 and R2)

The investigation revealed of the following: Allegation "Staff are not following physicians orders to check blood pressure/ blood sugar" LPA interviewed R1 and reported that the staff did not check her blood sugar on a daily basis. LPA interviewed staff and stated they do not check R1 blood sugar daily as its not required. LPA reviewed R1's interdisciplinary discharge plan dated on 11/12/2021 and physician report dated on 11/12/21 and it was indicated that R1 required finger stick blood sugar and insulin Lispro sliding scale. LPA reviewed R1's file and it has no discontinuation papper about those orders. (See LIC9099C 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: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20211206123535
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: 12/09/2021
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
26
27
28
29
30
31
32
Based on interviews conducted, observation and records review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit Interview was conducted with the Administrator, Chanel Sanchez and a copy of report and appeal right was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20211206123535
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: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2021
Section Cited
CCR
87465(a)(2)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility(2)The licensee shall provide assistance in meeting necessary medical and dental needs. The requirement is not met ad evidenced by :
1
2
3
4
5
6
7
The administrator will ensure the provide assistance in meeting necessary residents' medical needs. The administrator will retrain the staff and ensure each resident has a plan for their incidental medical and dental care and send the staff training log to LPA by POC due date.
8
9
10
11
12
13
14
record review and R1's interview, LPA reviewed R1 phyisican report and discharge paper and R1 required insulin Lispro Sliding scale and finger stick blood sugar and there's no discontinuation paper from doctor in R1's file and facility is not following doctor's order
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5