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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 451373915
Report Date: 12/13/2023
Date Signed: 12/13/2023 03:08:10 PM


Document Has Been Signed on 12/13/2023 03:08 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:WOODCLIFF CARE HOMEFACILITY NUMBER:
451373915
ADMINISTRATOR:CALLOWAY, JAIMEFACILITY TYPE:
740
ADDRESS:165 WOODCLIFF DRIVETELEPHONE:
(530) 244-2467
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 6DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Direct Care Staff Marlet GulbrantsonTIME COMPLETED:
03:25 PM
NARRATIVE
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 On 12/13/ 2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Direct Care Staff Marlet Gulbrantson and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 113 F. LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detector. LPA observed the first aid kit which contained all the requirements. LPA observed toxic chemicals stored under the sink.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of six (6) residents' files and five (3) staff files. Two of three staff files reviewed are missing TB testing and results. Two of six residents had half bed rails without an order from a medical provider.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.


Several topics were discussed.

An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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 5


Document Has Been Signed on 12/13/2023 03:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WOODCLIFF CARE HOME
FACILITY NUMBER: 451373915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one cleaning solution was found under the sink in the kitchen which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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Administrator will train staff of the importance of storing cleaning solutions and provide proff to the LPA.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with Adminstrator and record review, the licensee did not comply with the section cited above in two of six residents with postural supports do not have a medical order which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Adminstrator will provide the LPA with medical documentation for the need of postural supports for the residents.
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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5