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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005960
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:38:21 AM


Document Has Been Signed on 12/15/2022 11:38 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:PRATT, STEPHENFACILITY TYPE:
740
ADDRESS:1 WITHERSPOONTELEPHONE:
(949) 654-8500
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:180CENSUS: 117DATE:
12/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Terrie Sherrell, Assisted Living DirectorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Kathrina Chin made an unannounced case management visit to the facility to follow up on special incident report dated October 18, 2021 for R1. LPA met with Terrie Sherrell, Assisted Living Director and Myra Aragones, Executive Director.

The Department investigation conducted revealed the following:

On September 16, 2021, R1 was taken for a medical appointment to UCI Medical Center for the vaginal bleeding in which R1’s responsible party observed during R1’s home visit. The primary physician did not know the cause of the R1’s vaginal bleeding and referred R1 to see an Obstetrics Gynecologist. The Obstetrics Gynecologist was concerned that there might have been elder abuse because the doctor found some five-inch-long detached free-standing hairs deep in R1’s vagina mixed with blood. The doctor found the bleeding and the hairs to be unusual.

R1’s responsible party read the doctor’s finding and visit online. R1 was moved out of the facility on October 18, 2021. Resident resided at the facility from September 09, 2021 to October 18, 2021. The doctor did not recommend a “rape kit” be performed because the doctor did not suspect sexual abuse.

The Irvine Police Department Detective noted that R1 denied sexual abuse. R1’s doctor noted the bleeding and the discovery of hair were not necessarily the result of sexual abuse. No female residents in the Memory Care Unit where R1 did not see anything suspicious regarding a sexual assault incident. (Continued on LIC 809C)
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/15/2022
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Currently, it is unknown if those hair belong to R1. There is no evidence to suggest that R1 was sexually assaulted while at facility. R1 is very verbal and if she was being sexually assaulted for weeks, the chances are great that she would have reported it to her children. There is no corroborating evidence to prove that R1 was sexually assaulted at the facility.

No deficiencies were cited as per Title 22 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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