496804124-3-9-2023-21-AS-VBEI-CPRQBG-20230309110131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804124
Report Date: 03/09/2023
Date Signed: 03/09/2023 11:01:43 AM

Document Has Been Signed on 03/09/2023 11:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	WOODWARD ASSISTED LIVING		FACILITY NUMBER:	496804124
ADMINISTRATOR:	TADURAN, GLORIA		FACILITY TYPE:	740
ADDRESS:	1825 WOODWARD DR		TELEPHONE:	(707) 710-3134
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 5	DATE:	03/09/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Applicant, Gloria Taduran		TIME COMPLETED:	11:11 AM

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 Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Pre-Licensing Inspection and met with Applicant, Gloria Taduran. Applicant has applied for a Change of Ownership at this location that currently has 5 residents in care. LPA initiated a tour of the facility at approximately 9:00am and made the following observations: Facility is a one story residence with two single resident bedrooms, two shared resident bedrooms, three bathrooms and common areas. Passageways were free from obstruction. All resident rooms are furnished per regulation. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathrooms read at 110 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. LPA discussed rotating food so that food doesn't expire. Facility backyard has an area for visiting and activities. During inspection, LPA learned that the bathroom dedicated for resident's showers is located through a resident room which is not allowable per regulation. Applicant showed LPA that a curtain is used for privacy and the residents in that room agreed to the use of the shower by other residents. LPA discussed with the Applicant and indicated that they may request a waiver from the Department to be able to use the shower for all residents. Facility received an approved fire clearance dated November 28, 2022 that allows for five non-ambulatory residents and one bedridden resident. Fire Extinguishers were last serviced December 2022. Carbon Monoxide detectors were tested and operational. Facility has lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage. Emergency food and water supplies are stored in the kitchen pantry. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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: WOODWARD ASSISTED LIVING	FACILITY NUMBER: 496804124
	VISIT DATE: 03/09/2023

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Continued from LIC809

LPA observed required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils.

Medications and files are secured in a locked cabinet in the kitchen. LPA and Applicant discussed that all resident files would need to be updated upon Licensure. LPA confirmed that Applicant will sign up for the Guardian and Provider Information Notices (PINs) that the Department sends out.

Component III was conducted with Applicant.

Once waiver is received and approved, LPA will work with the Application Unit to continue with the Application process.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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