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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005960
Report Date: 07/11/2024
Date Signed: 07/11/2024 10:01:49 AM


Document Has Been Signed on 07/11/2024 10:01 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:WOODBRIDGE TERRACEFACILITY NUMBER:
306005960
ADMINISTRATOR:MYRA LOZADA ARAGONESFACILITY TYPE:
740
ADDRESS:1 WITHERSPOONTELEPHONE:
(949) 654-8500
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:180CENSUS: 129DATE:
07/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:23 AM
MET WITH:Christian Otbo and Susanna MoraTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 06/26/2024. LPA was greeted and granted entry by Reception Rosa Leaning and explained the reason for the visit. Executive Director Christian Otbo arrived during the visit.

Incident report dated 06/26/2024 indicated Resident 1 (R1) had reported that the resident's private caregiver (PC) had hit the resident. Irvine Police responded, case #24-06954, and determined no criminal activity had occurred. Facility interviewed Resident who changed the story upon interview. Facility interviewed private caregiver who denied the accusation stating that the private caregiver had placed his hand on the resident's neck to guide him to restroom. Facility contacted staffing agency to request the private caregiver not be placed in facility again due to allegation.

Per physician report dated 02/09/2024, R1 is diagnosed with Metabolic Encephalopathy and Mild Cognitive Impairment. Physician report indicates resident is confused/ disoriented. LPA is unable to interview resident as resident has moved out of the facility.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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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