306005521-2-29-2024-22-AS-CGUZ-D2WQW4-20240229113119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005521
Report Date: 02/29/2024
Date Signed: 02/29/2024 11:31:33 AM

Document Has Been Signed on 02/29/2024 11:31 AM - 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 HOMES		FACILITY NUMBER:	306005521
ADMINISTRATOR:	GARCIA, ANNA C		FACILITY TYPE:	735
ADDRESS:	11601 STEPHANIE LN		TELEPHONE:	(714) 458-5992
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY: 3		CENSUS: 3	DATE:	02/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Anna Garcia		TIME COMPLETED:	11:50 AM

NARRATIVE

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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Staff Felix Aguilar and explained the purpose of the inspection. Administrator (AD) Anna Garcia was contacted by phone and arrived at 10:00 a.m.

During the inspection LPA and Staff Aguilar conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with three bedrooms and two bathrooms. LPA observed a storage room is currently being used as a staff bedroom; a Deficiency was cited on today’s date. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA did not observe any clients present, as they were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 109.0-117.6 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated 12/15/23. Gas stove, microwave, washer, and dryer were all inspected. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed three client files and three staff files. Clients were not present to be interviewed. LPA interviewed staff present.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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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Document Has Been Signed on 02/29/2024 11:31 AM - It Cannot Be Edited

Created By: Claudia Gutierrez On 02/29/2024 at 10:40 AM

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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WOODBURY HOMES	FACILITY NUMBER: 306005521
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85087(a)(3)

Building and Grounds

(3) No room commonly used for other purposes shall be used as a bedroom for any person. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and staff interview, the licensee did not comply with the section cited above, as a storage room is currently being used as a staff bedroom, which poses a potential personal rights risk to persons in care.
	POC Due Date: 03/29/2024
	Plan of Correction
1 2 3 4	AD stated LIC200, facility sketch, and $25 check would be submitted to regional office by POC date to designated storage room as a staff bedroom.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Claudia Gutierrez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

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