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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005521
Report Date: 02/26/2025
Date Signed: 02/26/2025 11:00:23 AM

Document Has Been Signed on 02/26/2025 11:00 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 HOMESFACILITY NUMBER:
306005521
ADMINISTRATOR/
DIRECTOR:		GARCIA, ANNA CFACILITY TYPE:
735
ADDRESS:11601 STEPHANIE LNTELEPHONE:
(714) 740-5358
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 3CENSUS: 3DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:43 AM
MET WITH:Anna GarciaTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Anna Garcia and discussed the purpose of the inspection.

LPA reviewed Infection Control requirements. At about 8:00AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with attached garage that is used for storage. There is a back yard with a patio cover for the clients. LPA observed 2 care staff and 2 clients present at the facility. Client Bedrooms: the 3 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: LPA inspected the one staff bedroom which has been properly cleared as a staff bedroom on April 9, 2024 by the Orange County Fire Authority. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 119 in the two bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the cleaning closet. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:00AM, LPA reviewed 3 client files and 3 staff files, interviewed 2 clients and 2 staff, inspected medications for 3 clients, and inspected client money and ledgers for 3 clients.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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Document Has Been Signed on 02/26/2025 11:00 AM - It Cannot Be Edited


Created By: Sean Haddad On 02/26/2025 at 10:37 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: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure cold medication, pain medication, and other medications were inaccessible to clients in the non-lockable front closet, which poses an immediate health risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
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During the inspection, the licensee secured these items and LPA confirmed. Licensee stated they search the facility to ensure all dangerous items are secured, will train staff on securing dangerous items, and submit proof to LPA by 03/05/25
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/26/2025 11:00 AM - It Cannot Be Edited


Created By: Sean Haddad On 02/26/2025 at 10:37 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: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85165(b)(2)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents and admission, the licensee's CPI training for all staff expired about a month ago and the licensee has already scheduled a renewal training, which poses a potential safety risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Licensee stated they will submit proof that the renewal CPI training has been scheduled to LPA by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 02/26/2025
NARRATIVE
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During the inspection, LPA and AD observed the following: based on observation, the licensee did not ensure cold medication, pain medication, and other medications were inaccessible to clients in the non-lockable front closet; and based on documents and admission, the licensee's CPI training for all staff expired about a month ago and the licensee has already scheduled a renewal training.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
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