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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200817
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:04:14 PM

Document Has Been Signed on 06/10/2024 04:04 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:WOODYEAR HOME, THEFACILITY NUMBER:
198200817
ADMINISTRATOR/
DIRECTOR:		ROBERT M. WOODYEARFACILITY TYPE:
735
ADDRESS:13234 FLORWOOD AVENUETELEPHONE:
(310) 973-5043
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: 3DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:29 PM
MET WITH:Robert M. Woodyear, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 06/10/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Robert Woodyear and explained the purpose of today’s visit. The facility is licensed to serve developmentally disabled residents ages 18 to 59 years.


LPA Felisa and Menelik Flores, Staff toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, (2) bathroom, living room, den, kitchen, dining area, patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1 and 2 are occupied by residents and contain the mandated furniture. Bedroom 3 is vacant. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Menelik toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. LPA observed that the stove had one on the stove that was not working. Knives were locked and stored. The medications were locked and stored in cabinets in the hallway. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 109.4 degrees Fahrenheit.

Con'd on 809-c

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817
VISIT DATE: 06/10/2024
NARRATIVE
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First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Menelik walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

During search on website, LPA Shirley observed that the Administrators Certificate is not valid. LPA did not have access to the staff records.

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 Woodyear/Administrator at the time of the visit.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2024 04:04 PM - It Cannot Be Edited


Created By: Felisa Shirley On 06/10/2024 at 03:22 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients employees and visitors.




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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Administrator shall provide proof of repair of the front right eye of the stove by POC date of 6/24/24 via fax or email to felisa.shirley@dss.ca.gov.
Type B
Section Cited
CCR
80044(c)(1)
80044 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records may removed if necessary for copying. Removal of records shall be subject to the rquirements specified in Sections 80066(c) and 80070(d). (1) The licensee shall ensure that provisions are made for the examination of all records relating to the operation of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in which not having access to staff records poses a potential safety risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Administrator shall review regulation and provide written proof of understanding of regulation by POC due date of 6/24/24 via fax or email to felisa.shirley@dss.ca.gov
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2024 04:04 PM - It Cannot Be Edited


Created By: Felisa Shirley On 06/10/2024 at 03:55 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
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: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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3
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Administrator shall provide proof of payment of Administrators Certificate by POC due date of 6/24/24 via fax or email to felisa.shirley@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


LIC809 (FAS) - (06/04)
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