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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200817
Report Date: 08/08/2025
Date Signed: 08/08/2025 05:24:31 PM

Document Has Been Signed on 08/08/2025 05:24 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
08/08/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:02 PM
MET WITH:Menelik FloresTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 08/08/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Continuation Visit to the facility listed above. LPA met with Staff, Estela Briseno, and the purpose of today’s visit was explained. We were later joined by Staff Menelik Flores. LPA was granted entry into the facility. The facility is licensed to serve four (4) ambulatory developmentally disabled adults ages 18 to 59.
Physical Plant/Structure The facility is a single-story structure in a residential neighborhood. The facility consists of three (3) bedrooms, two (2) bathrooms, living room, dining room, kitchen, detached garage used for storage and a laundry area, and a shaded patio. LPA did observe walkways around the facility were clean, clear, and free of debris, hazards, and obstructions. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all Client bedrooms and observed them to be clean and in good repair. All bedrooms were observed with the required furniture, including a bed, dresser, nightstand, chairs, and storage space for resident’s personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of bed linens in a closet in the hallway in good repair.
Bathrooms LPA inspected all bathrooms and observed them to be operable and within Title 22 regulations. LPA observed all showers to be clean and free of mildew and mold. LPA observed nonskid material in the showers. LPA observed Client toiletry boxes stored in a closet in the hallway. LPA observed an ample supply of towels and washcloths stored in a closet in the bathroom. The water temperature in the bathrooms measured 116.3-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. All appliances were observed operable and in good repair. LPA observed an ample supply of cookware, dishware and cutlery. LPA
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WOODYEAR HOME, THE
FACILITY NUMBER: 198200817
VISIT DATE: 08/08/2025
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observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods properly stored. The water temperature measured 115.6-degrees Fahrenheit. LPA observed sharps secured in a locked drawer in the kitchen and are inaccessible to Clients. LPA observed cleaning supplies secured in a locked cabinet under the kitchen sink and are inaccessible to Clients. LPA observed a fully charged fire extinguisher.
Common Rooms LPA observed the dining room has a large table and chairs to accommodate Clients. LPA observed the living room has two couches available for Clients. LPA observed a fireplace screened and inaccessible to Clients. LPA observed games and activities available for Client use. LPA observed all rooms have ample lighting. The facility was maintained at a comfortable temperature. All walkways and hallways inside the facility were observed clean and clear of obstructions and hazards. The facility was appropriately furnished during the time of visit.
Files LPA reviewed the files for the Administrator and two (2) staff. LPA observed there were a few documents missing and certification had expired. (Please see Technical Violations and LIC9099D attached).

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See attached LIC9099-D pages for Citations.

An exit interview was conducted with Staff Menelik Flores, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2025 05:24 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 08/08/2025 at 04:50 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: 08/08/2025

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 four out of four Staff S1-S4 CPR and First Aid Expired in June 2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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The Licensee will ensure staff are provided First Aid and CPR training by POC due date. Licensee will email LPA Staff S1-S4's current CPR and First Aid
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.
Eva M Alvarez
NAME OF LICENSING PROGRAM MANAGER:
Wendy Gibbs
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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