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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004514
Report Date: 09/22/2022
Date Signed: 09/22/2022 12:06:34 PM


Document Has Been Signed on 09/22/2022 12:06 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:NORTHWOOD CARE HOMEFACILITY NUMBER:
306004514
ADMINISTRATOR:TERESA ALPUERTOFACILITY TYPE:
740
ADDRESS:7 BRAGGTELEPHONE:
(949) 653-5742
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
09/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gloria De Guzman- Caregiver and Danilo De Guzman- House Manager TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 09/16/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Caregiver, Gloria De Guzman. Danilo De Guzman, House Manager arrived 11:30 AM.

Incident report indicated Resident 1 (R1) went to Kaiser due to slip and fall on 09/15/2022.

Per interview with staff 1 (S1) was assisting R1 to bed, R1's legs gave out and R1 started to fall. S1 went to grab R1, but R1's elbow hit the floor. S1 called House Manager Danilo De Guzman over to the room. Danilo called 911 and paramedics assessed R1. R1 was then taken to hospital for further evaluation with Danilo De Guzman. Facility staff notified Administrator Teresa Alpuerto and R1's responsible party.

R1 returned to facility the next morning with a diagnosis of a fractured upper arm.


During the visit, LPA reviewed LIC 602, Individual Program Plan (IPP) and hospital discharge paperwork.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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