486801578-6-29-2021-21-AS-EGCS-C4FTWK-20210629150541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801578
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:06:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	WOODRIDGE RESIDENTIAL CARE II		FACILITY NUMBER:	486801578
ADMINISTRATOR:	CARTEL, JULLY		FACILITY TYPE:	740
ADDRESS:	738 OAKWOOD AVE.		TELEPHONE:	(707) 557-5939
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	06/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator, Jully Cartel		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA), Farhaan Sarangi and Erik Gonzalez Campos arrived unannounced to conduct a Required 1 year inspection at approximately 1:45 PM, and met with administrator Jully Cartel. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPAs were screened for COVID symptoms and asked to sign in by S1. At primary entrance LPAs observed temperature logs and visitor sign-in sheet. LPAs conducted walk through of the facility with S1 and observed COVID postings throughout. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPAs confirmed facility has necessary PPE and supplies to support a resident in isolation. During the Required 1 year inspection, LPAs observed hot water temperature being at 95 degrees Fahrenheit in 1 resident bathroom and the kitchen. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Per Title 22-87303(e)(2)-Maintenance and Operation. Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. A 30 day supply of medications are stored in a locked cabinet, making them inaccessible to residents. All exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines Continued on LIC 809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WOODRIDGE RESIDENTIAL CARE II	FACILITY NUMBER: 486801578
	VISIT DATE: 06/29/2021

NARRATIVE

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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPAs observed dish washing soap in an unlocked cabinet under the kitchen sink. A Technical Violation was noted (See LIC 9102) for the dish soap being unlocked.

LPAs reviewed and approved mitigation plan at the facility.

LPAs requested following documents:

LIC 309
LIC 400
Liability Insurance
Administrator Certificate
LIC 402

Deficiencies were observed on June 29, 2021 at 01:45 PM, and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given to the Administrator. A copy of this report was signed by the Administrator and emailed to the Administrators email on file.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WOODRIDGE RESIDENTIAL CARE II	FACILITY NUMBER: 486801578
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation during the Required 1 year inspection on June 29, 2021, the licensee did not comply with the section cited above due to 1 resident bathroom and the kitchen faucet emiting a 95 degree temperature of water which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2021
	Plan of Correction
1 2 3 4	Facility will fix the hot water temperature in seven days and provide a log for seven days after the hot water is fixed to ensure hot water temperature is being provided inside the home for residents in care.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC809 (FAS) - (06/04)

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