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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803966
Report Date: 10/28/2021
Date Signed: 10/28/2021 05:32:57 PM

Document Has Been Signed on 10/28/2021 05:32 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:WOODWARD ASSISTED LIVINGFACILITY NUMBER:
496803966
ADMINISTRATOR:AMADOR, ADAFACILITY TYPE:
740
ADDRESS:1825 WOODWARD DR.TELEPHONE:
(530) 308-6230
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: DATE:
10/28/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Ada AmadorTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced at approximately 2:30 PM to conduct a post-licensing inspection. LPA was greeted by staff and asked to sign in. LPA observed staff as well as a visitor not wearing a mask. Administrator, Ada Amador arrived later.

Upon questioning staff, S1 revealed to LPA they have been working at the facility since July and have never been fingerprinted. LPA was unable to locate S1 on facility roster. LPA and administrator called regional office to check fingerprint status of S1. Regional office was unable to locate S1 in guardian database.

The amount of fresh and nonperishable foods is within regulation. Toxins are stored in locked laundry room and are therefore inaccessible to residents in care. Water temperature measured at 117.1 degrees F which is within within regulation between 105 and 120 degrees F at faucets accessible to residents. Smoke detectors were tested and found to be in working order. Carbon Monoxide detector was present. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings.

LPA provided guidance to review PIN 21-38 regarding mask requirements and to submit a COVID mitigation plan. Administrator was unable to provide staff training records.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6. Civil penalty assessed in the amount of $500. Appeal rights given. Exit interview was conducted and a copy of this report was given to the administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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Document Has Been Signed on 10/28/2021 05:32 PM - It Cannot Be Edited


Created By: Erik Gonzalez Campos On 10/28/2021 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496803966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468(a)(2)
87468 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Administrator/Licensee did not ensure S1 nor visitor was wearing a mask as reflected in current CCL requirements. This poses an immediate risk to the health, safety and personal rights of the residents in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee will ensure Personal Rights of residents are maintained. Licensee agrees to submit proof of training for mask requirement for all staff as well as submit COVID mitigation plan by POC date of 11/05/2021.
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, S1 at the time of the inspection indicated they have been working at the facility since July and have never been fingerprinted, LPA unable to locate S1 in guardian database, which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty is assessed in the amount of $500.00.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee to remove S1 from facility and future shifts until they have been fingerprint cleared and associated to the facility. Licensee agrees to submit documentation to associate S1 to facility by POC due date of 11/05/2021.
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
LICENSING EVALUATOR NAME:Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


LIC809 (FAS) - (06/04)
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