496804124-3-22-2024-21-AS-CCOO-D3LRRK-20240322131516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804124
Report Date: 03/22/2024
Date Signed: 03/22/2024 01:15:34 PM

Document Has Been Signed on 03/22/2024 01:15 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:	WOODWARD ASSISTED LIVING		FACILITY NUMBER:	496804124
ADMINISTRATOR:	TADURAN, GLORIA		FACILITY TYPE:	740
ADDRESS:	1825 WOODWARD DR		TELEPHONE:	(707) 843-7268
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 6	DATE:	03/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Gloria Taduran, Administrator		TIME COMPLETED:	01:30 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 Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Gloria Taduran. Facility contact information was reviewed. At approximately 9:15am LPA and Admin toured the building and grounds. The facility was found to have black spots of film around sink in grout, ants in the pantry, and both bugs and dead ants in cabinet under the sink in kitchen. Per Title 22 regulation 87555(b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects (deficiency cited, see 809D). The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered, but not labeled with date of use. Admin will be sure to label all left over food. Kitchen cabinet containing cleaning supplies was locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required grab bar and mats. Water temperature in sink accessible to residents in care measured at 108.8 degrees F which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 12/4/2023. Smoke/Carbon Monoxide detectors located throughout the facility were last tested and operational by vendor on 11/15/2023. Facility’s last quarterly disaster drill was conducted on 3/5/2024. Facility has a backup generator for use during a power outage. At approximately 10:30am LPA conducted a review of 6 resident and 5 staff records. All required documents and training present. At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the kitchen. Continued on 809C...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

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: 03/22/2024

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
26
27
28
29
30
31
32

Continued from 809...

Gloria Taduran Administrator Certificate 6063245740 expired 3/17/2024, but Admin said she submitted the renewal yesterday 3/21/24. Linberge Yumul Administrator certificate #7031395740 expires 1/14/2025 and per Taduran, Yumul is the Admin of the facility jointly with her. LPA advised Admin that in addition to changing his job description on Guardian roster, Admin must submit to CCL the required documents so that CCL can approve the addition. Admin will send to CCL within 30 days from today, 3/22/2024. Facility fees are due. LPA gave LIS print out showing dollar amount due along with PIN to make payment via portal and advised Admin about fee due.

LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

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
LIC308- Designation of Responsibility
Plan of Operation
Evidence of Liability Insurance- Declarations Page

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 03/22/2024 01:15 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING	FACILITY NUMBER: 496804124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the facility was found to have black spots of film around sink in grout, ants in the pantry, and both bugs and dead gnats in cabinet under the sink in kitchen, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Facility to submit LIC9098 self-certifiying all items have beeb cleaned and corrected: black spots of film around sink in grout, ants in the pantry, and both bugs and dead ants in cabinet under the sink in kitchen

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6