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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005960
Report Date: 11/05/2024
Date Signed: 11/05/2024 04:46:30 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
10/28/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20241028120627
FACILITY NAME:WOODBRIDGE TERRACEFACILITY NUMBER:
306005960
ADMINISTRATOR:CHRISTIAN OTBOFACILITY TYPE:
740
ADDRESS:1 WITHERSPOONTELEPHONE:
(949) 654-8500
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:180CENSUS: 135DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Daizy Gonzalez, Residents Relations DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is accepting bedridden residents, but do not have an approved fire clearance for it.
Facility is not adhering to physician reports
INVESTIGATION FINDINGS:
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This unannounced investigation inspection by Licensing Program Analysts (LPAs) Dwayne Mason Jr. and William Vanegas is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPAs arrived at the facility and were greeted by facility staff. LPAs met with Daizy Gonzalez, Residents Relations Director and explained the nature of the inspection.

The department received a complaint on 10/28/2024 stating the facility is accepting bedridden residents, but do not have an approved fire clearance for it and that the facility is not adhering to physician 's reports. During the investigation, the Department interviewed staff and residents in care.

(continued on LIC9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20241028120627
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WOODBRIDGE TERRACE
FACILITY NUMBER: 306005960
VISIT DATE: 11/05/2024
NARRATIVE
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(continued from LIC9099)

On 11/5/2024 LPAs conducted a visit to the facility. LPAs obtained copies of the personnel report, resident roster, physician's reports and physician's orders. LPAs toured the facility, interviewed staff, made observations of resident rooms and reviewed records.

LPAs observed 4 residents (R1, R2, R3, R4). It was reported that R1 is bedridden. Based on record review, it was found that R1 is non-ambulatory. R2, R3 and R4 were observed with hoyer lifts in their rooms. LPAs reviewed current physician's orders for hoyer lifts for R2, R3 and R4.

Based on records reviewed and observations made, LPAs determined that the facility is not accepting bedridden residents. Based on records reviewed and observations made, LPAs determined that the facility is adhering to physician reports.

Based on LPAs' observations and review of documents obtained, these allegations are UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2