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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198200817
Report Date: 08/24/2021
Date Signed: 08/24/2021 09:07:00 PM

Substantiated


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 DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/26/2021 and conducted by Evaluator Jey Cardenas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210726084027
FACILITY NAME:WOODYEAR HOME, THEFACILITY NUMBER:
198200817
ADMINISTRATOR:ROBERT M. WOODYEARFACILITY TYPE:
735
ADDRESS:13234 FLORWOOD AVENUETELEPHONE:
(310) 973-5043
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:4CENSUS: 4DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Lakeisha JonesTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Facility is out of ratio.
Resident's IPP plan does not include items that must remain locked.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced subsequent complaint visit to the above facility to deliver findings for the allegations listed above. Upon arrival at the facility LPA conducted a risk assessment with DSP staff#2 (S2), Also present during visit was S1. Based on the assessment, the facility is clear of Covid-19 infection. The purpose of the visit was explained. LPA was later met by Robert Woodyear.

Investigation consisted of: LPA conducted interviews with Administrator, Woodyear, staff, reviewed client facility files, and toured physical plant.

Re: allegation: Facility is out of ratio. On 8/02/21 LPA made a visit to the facility upon arrival LPA observed one (1) staff and four clients present. LPA Cardenas reviewed C1’s IPP which indicates facility is vendored by Westside Regional Center as a CCF Level 4F, and program design requires a 1:3 ratio at all times. C1 also receives 108hrs per month of supplemental staffing to have a 1:1 level of support.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 11-AS-20210726084027
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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817
VISIT DATE: 08/24/2021
NARRATIVE
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Per IPP C1 requires supervision at all times for safety and well-being. LPA Cardenas reviewed Plan of operation for The Woodyear Home staffing schedule; schedule shows two (2) staff on schedule for most of the day except 9am-2pm when clients are off-site at day program. Due to the Covid-19 pandemic, the clients were remote learning from the facility.

Re: allegation: Resident's IPP plan does not include items that must remain locked. On 8/02/21 S1 and administrator indicated that C1 has behaviors that require hygiene items and some snacks to be locked up. Administrator indicates that C1 likes to take items and hide them. LPA Cardenas reviewed IPP dated 10/07/2020 and didn’t observe approved plan to lock up items for behavior/ safety reasons.

Based on LPA’s observations, interviews, and record review(s), the preponderance of evidence standard has been met, therefore the allegations, are found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D.

Exit interview conducted copy of report and appeal rights to be emailed to email on file.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20210726084027
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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
CCR
85065.5(a)(1)
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Day Staff-Client Ratio For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients. This requirement not met

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Facility shall submit LIC500 personnel report/ schedule to ensure ratios are being maintained.

****During LPAs visit on 8/24/2021 LPA observed two (2) staff on shift.
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as evidenced by: On 08/02/2021 LPA observed one (1) staff on shift and four (4) clients present at the facility. Facillity is a 4F level home and shall maintaine 1:3 ration. This poses a potential health and safety risk to clients in care.
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Type B
08/27/2021
Section Cited
CCR
80068.3(a)
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Modifications to Needs and Services Plan. The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy. This requirement not met as evidenced by: On 8/24/21 LPA reviewed
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Administrator will ensure IPP is updated to reflect residents behaviors. Administrator to submit self-certifiation indicating behaviors and prevention methods will be discussed, IPP updated.
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IPP on file and resident has behaviors that require items to be locked up. Resident's IPP plan was not updated to include items that must remain locked.
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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.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3