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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800629
Report Date: 05/23/2024
Date Signed: 05/23/2024 12:04:31 PM

Document Has Been Signed on 05/23/2024 12:04 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WOODRIDGE HOMEFACILITY NUMBER:
486800629
ADMINISTRATOR/
DIRECTOR:		EMILIA BERALDEFACILITY TYPE:
735
ADDRESS:184 WOODRIDGE CIRCLETELEPHONE:
(707) 447-5572
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 3DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Emilia Beralde, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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At approximately 9:15 AM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced Annual Required inspection to this facility and met with Emilia Beralde, Administrator. At approximately 9:30 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed debris and toxins in the backyard (motor oil, paint can, and paint chemicals. Administrator secured during visit. LPA advised Administrator to remove (wood and bed frame located near backyard gate closest to clients rooms) and secure toxic chemicals so they are not accessible to clients. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. LPA observed decayed (celery was discolored ranging from whitish light green to brown)and expired food items (container of food item expired on 05/02/2024), freezer items were not properly packaged and stored in the freezer and showed signs of freezer burn ( food was covered in approximately 1 inch of ice in folding sandwich bag that did not offer ziploc closure). Toxins inside the facility are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. LPA observed mattresses, Administrator advised client's sheets are changed once every 4 weeks. LPA advised Administrator clients sheets must be changed within a reasonable time and more than 1 time a month. Per Administrator she changes her own sheets 1 time a week. LPA advised Administrator, suggested client's sheets to be changed weekly especially with new client admission whom experiences incontinence . Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Two of two faucets accessible to clients measured between 114.3 and 116.3 degrees F, Two of two Fire extinguishers inspected were charged. Four out of four Smoke detectors and were tested and found to be in working order. Carbon Monoxide detector was present and in working order. Facility temperature was within regulation between 73 and 74 degrees F. Disaster Drills are conducted monthly with the last drill conducted 1/8/2024.


Continued on 809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WOODRIDGE HOME
FACILITY NUMBER: 486800629
VISIT DATE: 05/23/2024
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Continued from 809

At approximately 10:00 AM, LPA reviewed 3 of 3 Client records and 3 of 3 Staff records, which were all found to be well organized. 3 of 3 Client records are missing personnel rights 613. Administrator to submitt signed 613's by 05/31/2024. C1 file missing 602. Per Administrator, C1 admitted last week and working on 602. Administrator to provide C1 602 once received. First aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled. Administrator's Certificate #6023028735 was current with an expiration date of 12/11/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report (updated)
LIC308- Designation of Responsibility (updated)
LIC610D- Disaster Plan (updated with non-local evacuation site)
C1 602
613 (signed)

No citations issued during today’s visit
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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