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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005960
Report Date: 11/04/2022
Date Signed: 11/04/2022 10:45:24 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
02/15/2022 and conducted by Evaluator Kathrina Chin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220215161420
FACILITY NAME:WOODBRIDGE TERRACEFACILITY NUMBER:
306005960
ADMINISTRATOR:PRATT, STEPHENFACILITY TYPE:
740
ADDRESS:1 WITHERSPOONTELEPHONE:
(949) 654-8500
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:180CENSUS: 129DATE:
11/04/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Terrie Sherrell, Assisted Living Director/LVNTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff sleeping during shifts
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Kathrina Chin conducted an unannounced visit for the purpose of delivering the findings on a complaint investigation. LPA met with Terrie Sherrell, Assisted Living Director/LVN. LPA interviewed several staff members and other witnesses.

The investigation into the allegation that staff sleeping during shifts revealed the following:

On January 18, 2022, two care staff members were found sleeping in the Memory Care Department while caring for eight residents. Stephen Pratt, Executive Director reported that Staff 1, the HR Director, and Staff 2, the Memory Care Director conducted a random check at the facility on January 18, 2022 on Staff 3 and Staff 4 at approximately 4:30 AM and observed both staff members to be sleeping on the job. Both staff members were immediately suspended and are no longer working for the facility. The facility submitted both an unusual incident report and SOC 341 Report of Suspected Dependent Adult/Elder Abuse to the Licensing office and Ombudsman Office. Family members were also informed of the incident. (Continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
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 3
Control Number 22-AS-20220215161420
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: 11/04/2022
NARRATIVE
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 LPA Chin interviewed S1 and S2 who witnessed the two employees(S3 and S4) sleeping on the job on January 18, 2022.

Based on the information gathered during the investigation and review of all documents obtained, the following allegation that Staff sleeping during shifts is substantiated.

Based on LPA's observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiency is cited today as per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted along with appeal rights were provided and a copy of this report was left.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220215161420
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: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited
CCR
87415(a)(2)
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Night Supervision- In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. This requirement is not met as evidenced by: Based on record review, and interviews,
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The Administrator reported that the two employees no longer work at the facility.
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two employees were observed sleeping in the Memory Care Department by S1 and S2 on January 18, 2022. This poses an immediate health & safety risk to residents in care.
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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: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3