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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200817
Report Date: 06/15/2023
Date Signed: 06/15/2023 03:16:06 PM

Document Has Been Signed on 06/15/2023 03:16 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:TIME COMPLETED:
03:15 PM
NARRATIVE
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On 6/15/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Robert Woodyear/Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (4) developmentally disabled or Mentally Ill adults ages 18 through 59. Currently, the home has (4) ambulatory clients. The clients are from: Westside Regional Center. (1) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices.

The single-story residential house consisted of (3) client bedrooms, (2) bathrooms, dining room, living room, kitchen, outdoor patio, backyard, laundry room and storage room.

LPA Iniguez and administrator toured the inside and outside of the facility (See D page for citation). All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 113.9F°, Bathroom #1 116.6°F., Bathroom #2 115.8F°).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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 5
Document Has Been Signed on 06/15/2023 03:16 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 06/15/2023 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in having debris in the back yard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee will ensure back patio will be cleared and a shaded area will be provided to the clients. A proof of correction will be sent to LPA via email or phone before POC due date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in having complete staff records at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee will ensure all staff records will be comlpleted and avalaible at the facility at all times. A proof of correction will be sent to LPA via email before POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/15/2023 03:16 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 06/15/2023 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in not having a CPR card in the staff records LPA reviewed during annual visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee will ensure the CPR cards will be added to the staff records. A proof of correction will be sent to LPA via email before POC due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in not having the admissions agreement in the client records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee will ensure all client records are complete and available at the facility, including the AD. Licensee will submitt proof of correction to LPA via email before POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/15/2023 03:16 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 06/15/2023 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in having the ANS in the client records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee will ensure the ANS will be in the client records at all time. Licensee will submitt a proof of correction via email to LPA before POC due date.
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in not having the complete client records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee will ensure all client records will be completed and available at the facility. Lincensee will submitt proof of correction to LPA via email before POC due date
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817
VISIT DATE: 06/15/2023
NARRATIVE
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility fire drill was 5/15/2023.

LPA conducted a records review of (3) client records C#1-C#3, (3) staff records S#1-S#3(see D pages for citations) and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit. A technical Advise was given to Licensee regarding medication administration.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

See D pages for Citations.

Exit interview conducted and a copy of the appeal rights were given to Robert Goodyear/Administrator at the time of the visit.



SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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