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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801578
Report Date: 05/12/2022
Date Signed: 05/19/2022 10:31:58 AM


Document Has Been Signed on 05/19/2022 10:31 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WOODRIDGE RESIDENTIAL CARE IIFACILITY NUMBER:
486801578
ADMINISTRATOR:CARTEL, JULLYFACILITY TYPE:
740
ADDRESS:738 OAKWOOD AVE.TELEPHONE:
(707) 557-5939
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 1DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Jully CartelTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, care staff, Mariquita Soberano (S1), Administrator, Jully Cartel arrived a few minutes later. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. The facility currently has 1 residents in care. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 1 of the residents.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was reviewed by the department on 7/21/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.
Fire Extinguisher was found to be charged and serviced 6/1/2021.
During today,s visit the facility was also found to have not been reporting incidents or deaths that occurred in the facility with the required forms and the admission agreement for the resident (R1) living in the facility was under this facilities sister facility and not Woodridge Residential Care II.
Exit interview conducted with Julyy Cartel

Per California Code of Regulations, (Title 22, Division 6), The following deficiency for key locked front door and locked perimeter gate was observed, and are being cited on the attached LIC 809-D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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Document Has Been Signed on 05/19/2022 10:31 AM - 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WOODRIDGE RESIDENTIAL CARE II
FACILITY NUMBER: 486801578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection and statement from administrator, there were several incident reports that may not have been reported to CCL, the licensee did not comply with the section cited above in 2 out of 2 residents were sent to the hospital and facility failed to report to CCL, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Facility to send in copies of incident reports and a statement or self certifiaction they understand reporting requirements regulation by POC date 5/25/22 to cler citation.
To: LPA Canela (707)588-5080 or by email Araceli.canela@dss.ca.gov
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed with administrator, the licensee did not comply with the section cited above in 1 out of 1 file for resident R1, did not have an admission agreement for this facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Facility to send in proof of correction or self certification to clear citation by 5/25/2022 to LPA A Canela

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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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