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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592947
Report Date: 06/14/2022
Date Signed: 06/14/2022 12:21:05 PM


Document Has Been Signed on 06/14/2022 12:21 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: 62DATE:
06/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Carmen Calicia TIME COMPLETED:
12:35 PM
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On 6/14/2022 at 9:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management inspection at the facility. LPA met with Administrator Carmen Galicia to discuss the purpose of the visit, which is to gather additional information regarding the SIR/UIR (unusual incident report) dated 6/10/22 for an incident involving Resident #1(R1) and Resident #2(R2).

According to the incident report, R1 struck R2 in the head with an aluminum cane. The incident resulted in R2 receiving a half-inch scar on the right side of the head. The facility called the police, and R1 was taken into custody.

During today's visit, LPA interviewed Administrator, staff (S1), R1, R2, R3 and R4. LPA reviewed R1 and R2 files and toured the facility with administrator. LPA did not observe signs of neglect, abuse, or other immediate health and safety threats. LPA obtained copies of the following documents:

Report continued on 809c
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WOODRUFF CARE HOME INC
FACILITY NUMBER: 191592947
VISIT DATE: 06/14/2022
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· Staff roster
· Resident roster
· Police report
· R1 individual service plan
· R1 Assessment Form
· R1 and R2 physicians report
· Copy of incident reports
· In service training record
· SOC 341


Interviews confirmed that R2 will go to R1’s room to visit R1’s roommate. R1 stated R2 stole $80 and 2 wallets from the room. LPA interviewed S1 who was present during the incident. S1 confirmed hearing a hollow noise but did not see the altercation because S1 was removing the trash. S1 confirmed calling for assistance when the altercation happened, and staff arrived with in 2 mins. Administrator stated facility called the police, completed SOC341, send incident report’s to CCLD, completed a physic evaluation for R1 (which will be faxed to LPA) and had an Inservice with staff. Administrator confirmed both residents had never exhibited aggressive behavior. Administrator plan to keep residents separated and to relocate R1 to a different room tomorrow 6/15/22. Administrator also stated R1 will use a walker and not a cane in the facility. LPA file review confirmed both residents do not have aggressive behavior as stated in the physician’s report.

During today’s visit, there were no deficiencies cited, per Title 22 regulations. Exit interview conducted and a copy of the report was given to Administrator Carmen Galicia during the exit interview.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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