306005960-6-23-2023-22-AS-AORZ-CU5PCC-20230727111141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005960
Report Date: 06/23/2023
Date Signed: 06/23/2023 11:26:56 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2023 and conducted by Evaluator Andrea Mendivil

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230620140023

FACILITY NAME:	WOODBRIDGE TERRACE		FACILITY NUMBER:	306005960
ADMINISTRATOR:	MYRA LOZADA ARAGONES		FACILITY TYPE:	740
ADDRESS:	1 WITHERSPOON		TELEPHONE:	(949) 654-8500
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	180	CENSUS: 144	DATE:	06/23/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Myra Aragones - Executive Director		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Facility did not make confidential information available upon request

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannouced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Susie Mora, Memory care director and explained the reason for the visit. Executive Direcotor Myra Aragones arrived shortly after.

The department received a complaint on 06/20/2023 and the initial 10 day visit was conducted on 06/23/2023. During the course of the invesitgation LPA Mendivil interviewed staff and reviewed records. Regarding the allegation that facility did not make confidential information available upon request, the investigation revealed the following:

It was reported by Executive Director (ED) Myra that the facility received a request for documentation on or around 06/08/2023. ED reported that the facility had a ransomware/cyberattack starting on 06/06/2023.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230620140023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WOODBRIDGE TERRACE	FACILITY NUMBER: 306005960
	VISIT DATE: 06/23/2023

NARRATIVE

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Based on review of emails facility legal department was made aware of the request and on 06/14/2023 responded to facility staff that the legal department will follow up on request. Per review of emails facility staff contacted their legal department again on 06/18/2023 and has not received a response. It was also noted on 06/14/2023 that the legal department would request an extension . Per interviews with witnesses the legal department has not requested an extension as of 06/22/2023.

Based on interviews with ED, the policy for internal documents is to request through their legal department and currently due to cyberattack it has delayed the request. Although the facility is currently facing a cyberattack, the facility has not produced the requested documents.

Therefore based on the preponderance of evidence through interviews and records review the allegation the Facility did not make confidential information available upon request is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230620140023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WOODBRIDGE TERRACE	FACILITY NUMBER: 306005960
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/07/2023 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	(c) All information and records obtained from or regarding residents shall be confidential.(1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative	1 2 3 4 5 6 7	Executive Director to follow up with legal department about extension request. ED to follow up about document request policy and provide a copy to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by facility has not provided documents to requestor. This poses a potential risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

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