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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005960
Report Date: 06/30/2022
Date Signed: 06/30/2022 03:00:47 PM


Document Has Been Signed on 06/30/2022 03:00 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:WOODBRIDGE TERRACEFACILITY NUMBER:
306005960
ADMINISTRATOR:PRATT, STEPHENFACILITY TYPE:
740
ADDRESS:1 WITHERSPOONTELEPHONE:
(949) 654-8500
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:180CENSUS: DATE:
06/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Giesla Marcial- Resident Care Supervisor, Jackie Francisco - Resident Care Coordinator, Stephen Pratt- Executive Director TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 06/21/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Giesla Marcial, Resident Care Supervisor and Jackie Francisco, Resident Care Coordinator and Executive Director Stephen Pratt.

Incident report indicated Resident 1 (R1) was assessed by paramedics due to facility's concern after R1 ingested a marijuana cookie.

Per interview with Jackie Francisco, Resident Care Coordinator, Med-tech Frances Pasqual noticed R1'sbehavior was different and R1 admitted to ingesting a marijuana cookie. Per Jackie Francisco, 911 was called and resident was assessed, R1 stayed in facility and was monitored.


During the visit, LPA reviewed LIC 602, medication list and facility's policy.



No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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