306005960-8-21-2024-22-AS-AROS-D8CSFV-20240821135055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005960
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:51:03 PM

Document Has Been Signed on 08/21/2024 01:51 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

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: 130	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Executive Director Christian Otbo		TIME COMPLETED:	02:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Required One Year visit to ensure substantial compliance with Title 22 regulations. According to the facility’s license, the facility has a maximum capacity of 180 non-ambulatory clients ages 60 and over, of which 140 may be non-ambulatory. Facility also has a hospice waiver for 20.

LPA was granted entry into the facility and was met by Executive Director (ED) Christian Otbo whom LPA discussed the purpose of the visit. LPA was accompanied by ED Otbo, during a tour of the facility, which was conducted inside and out including a sample of resident units, the dining area, recreation rooms, outside grounds, and food storage areas.. Exterior and interior passageways were free from obstructions. Pathways were free of obstruction and slip hazards. Smoke and carbon monoxide alarms are hard wired to a central location. All doors and elevators were operational.

Emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Each resident had clean and sufficient bed linens. Linens are kept in the individual rooms and extra linens towels, and washcloths are kept at facility in store room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: WOODBRIDGE TERRACE	FACILITY NUMBER: 306005960
	VISIT DATE: 08/21/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809]

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted and also available through a monthly community bulletin. Central cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked on medication carts. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Staff records review verified that all staff records are complete and compliant. All direct care staff have First Aide/CPR certificates, and staff training. Resident records reviewed and confirmed compliant. Administrator’s certification is current.

LPA reviewed the theft and loss policy and procedures. LPA conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted, this report was discussed with ED Otbo. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director,Otbo.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2