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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005521
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:02:28 PM

Document Has Been Signed on 02/25/2022 12:02 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:WOODBURY HOMESFACILITY NUMBER:
306005521
ADMINISTRATOR:GARCIA, ANNA CFACILITY TYPE:
735
ADDRESS:11601 STEPHANIE LNTELEPHONE:
(714) 458-5992
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 3CENSUS: 3DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Caregiver, Felix AguilarTIME COMPLETED:
12:20 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and was granted entry into the facility by Caregivers. Upon entry LPA's temperature was checked. LPA explained the reason for the visit.

LPA toured the facility with Caregiver Felix Aguilar, Facility is a 4 bedroom and 2 bathroom (3 client rooms, 1 staff room) single story home. There are 3 Clients in care. LPA observed facility has required Department postings. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained working water basin, working toilet, soap, toilet paper and paper towels. Facility has ample supply of clean linens and towels. Clients were observed relaxing in bedrooms.

Facility has PPE supply. Facility has refrigerator and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has 1 fire extinguisher which is fully charged. Facility has evacuation plan posted. LPA observed Administrator certificate expiring 9/22/2022. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. Clients emergency contact information and physicians reports are current. Facility has designated visitation area. Facility has a secured location for hazardous liquids and cleaning supplies.

An exit interview was conducted with Caregiver Aguilar and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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