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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804124
Report Date: 02/20/2025
Date Signed: 02/20/2025 04:13:27 PM

Document Has Been Signed on 02/20/2025 04:13 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 LIVINGFACILITY NUMBER:
496804124
ADMINISTRATOR/
DIRECTOR:		TADURAN, GLORIAFACILITY TYPE:
740
ADDRESS:1825 WOODWARD DRTELEPHONE:
(707) 843-7268
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 6DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:caregiver, LVNTIME VISIT/
INSPECTION COMPLETED:
04:27 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver, LVN. Administrator not available to come to the facility but was available periodically via telephone.

At approximately 9:00am LPA and caregiver toured the building and grounds. 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. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Black substance present in grout and spotted black film around sink in grout, LPA observed the same issue during last annual inspection dated 3/22/24 (deficiency cited, see 809D). Thick-it food and beverage thickener found in the pantry with prescription label torn off and date of expiration covering where label was. LPA advised this is a prescription item and cannot be shared between residents that do not have a prescription. LPA found zinc oxide and vitamin C in hall closet, unlocked and accessible to residents. LPA advised all vitamins and supplements must be stored inaccessible to residents.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms in good repair; however, there was a pervasive odor of urine incontinence present in the facility, coming from rooms #1 and #3 (deficiency cited, see 809D), odor was noticeable immediately upon entering the facility. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Bathroom in room #4 has a shower that has brown substance present in shower and chunks of a white substance concentrated over the drain. LPA advised caregiver, LVN that even if the shower is not presently used, it should remain clean. Water temperature in sink accessible to residents in care measured at 113.6 and 107.1 and degrees F which is within the allowable range of 105 to 120 degrees F.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 02/20/2025
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Fire extinguishers were last inspected today. Smoke/Carbon Monoxide detectors located throughout the are operational. Facility’s last quarterly disaster drills were conducted in 2024. LPA advised that drills must be performed quarterly. Facility has a backup generator for use during a power outage. LPA observed a discarded hospital bed partially obstructing the emergency fire exit path on the side of the house. LPA and caregiver discussed that fire exit cannot be obstructed (deficiency cited, see 809D).

At approximately 10:30am LPA conducted a review of 5 staff records. LPA reviewed training documents. Training log document shows staff training completed by instructors Administrator Gloria Taduran, RN and caregiver, LVN. Training completion dates listed as:
  • S1 hired 11/15/2023: 12/1/23: 5 hours training from CCO and 15 hours with a date 11/15, but no year listed
  • S2 hired 11/20/2023: 6 hrs 12/6/24, 5 hours on 12/12/24, 4 hours on 12/28/24, and 7 hours on 1/8/25
  • S3 hired 02/07/2024: 21 hours training on 2/7, but no year listed
  • S4 hired 11/29/2022: 15 hours on 5/1/24
  • S5 hired 04/06/2023: 15 hours on 4/4/24 and 7 hours on 4/7/24
  • S6 hired 01/20/2024: no training documented/on file
  • S7 hired 12/20/2024: no training documented/on file
LPA advised that if a staff member is within their first year of employment they must have completed 40 hours of training; 20 of which must be completed before working independently with residents; additionally, those staff that have completed their initial year of employment must complete a total of 20 hours annually (deficiency cited, see 809D).

LPA discussed with Admin and caregiver, LVN accuracy of date on which the training occurred. Admin and caregiver, LVN confirmed. LPA discussed with Admin and that there are only 24 hours in a day and therefore it appears that the training records have been fabricated. Admin and caregiver, LVN agreed to cease using handwritten training log and personal training materials. Admin and caregiver, LVN agree to

Continued on 809C(2)...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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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: 02/20/2025
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Continued from 809C...

instead use an approved vendor from which they will print the training completion certificates for each respective staff. The approved vendor they committed to using is Senior Community Learning. LPA discussed with Admin and caregiver, LVN that all personnel, whether on-call or full time must have their personnel file present at the facility. Full time regular staff (S7) and on-call staff (S6) did not have Health Screen, Training, TB, or any paperwork at all on file or present at facility (deficiency cited, see 809D). Staff (S2) has expired First Aid expired as of 1/10/2025 and staff (S4) did not have any First Aid on file (deficiency cited, see 809D). Staff (S6) was not associated to the facility, furthermore, they did not have any paperwork present at the facility (deficiency cited, see 809D).

At approximately 11:30am LPA conducted review of six [6] resident records. Four [4] of five [5] residents required to have half rails on order have half rail order present on file. LPA advised be sure all residents that have half rails present also have the half rail doctor orders on file. Resident (R1) has an appraisal on file but not current (11/2023) and residents (R2 and R3) did not have an appraisal on file at all (deficiency cited, see 809D)

At approximately 2:00pm LPA and caregiver, LVN conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Facility uses a MAR. LPA advised caregiver, LVN that a MAR is not required per regulation; however, if facility uses a MAR, then CCL can audit it. A few entries for residents missing on MAR but per caregiver, medication was administered. LPA advised that a PRN MAR is required per regulation. PRN MAR present. Prescribing physician entry missing for R3 on all Centrally Stored Medication Log (CSML) entries. LPA advised that recording the date started is not required per regulation but is a best practice. Caregiver, LVN agrees to start recording the date started on CSML. LPA discussed with caregiver, LVN crushing residents' medications. Caregiver, LVN advised LPA that they crush medications for two [2] residents to mitigate choking but could not produce a doctor's order or show where the medication is prescribed as needing to be crushed to be administered. Caregiver, LVN advised LPA they will get the doctor's order and maintain it in each respective resident's file.

Continued on 809C(3)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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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: 02/20/2025
NARRATIVE
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Continued from 809C(2)...

Gloria Taduran Administrator Certificate 7028332740, which is currently in Pending Renewal status.

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
Liability Insurance

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 caregiver, LVN. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with caregiver, LVN and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 02/20/2025 04:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/20/2025 at 03:16 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that S2 has expired First Aid/CPR exp 1/10/2025. S4 did not have any CPR/First Aid on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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2
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4
Facility to submit plan to have S4 and S2 complete First Aid/CPR training. Training to be completed no later than 3/6/25. Proof of First Aid/CPR certificate/card to be submitted to CCL no later than 3/6/25.
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that all staff: S1, S2, S3, S4, S5, S6 and S7 did not have required training completed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Facility to submit plan to have all staff complete required number of hours (as identified by their start date) of training by plan of correciton due date. Admin agrees to use Senior Community Learning for all staff training. Training certificates in the required number of hours for each respective staff: S1, S2. S3, S4, S5, S6, and S7 to be completed and sent to CCL by no later than 3/13/25.
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
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


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Page: 6 of 11
Document Has Been Signed on 02/20/2025 04:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/20/2025 at 03:16 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that Emergency fire exit path partially obstructed by hospital bed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Facility to remove broken hospital bed by plan of correction due date. Facility to submit pictures of cleared emergency fire exit as proof of correction.
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that S6 and S7 did not have Health Screen, Training, TB, or any paperwork on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
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Facility to submit Health Screen with TB clearance or LIC503, LIC501, and copy of First Aid/CPR for S6 and S7 to CCL by plan of correction due date.
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
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 02/20/2025 04:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/20/2025 at 03:16 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that Staff S6 was not associated to the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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2
3
4
Facility to submit to CCL facility Guardian roster print out showing S6 as being associated to the facility by plan of correction due date.
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
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2
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4
Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that black substance present in grout and spotted film around sink in grout, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
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2
3
4
Facility to submit to CCL pictures of grout around kitchen sink free of black substances and film by plan of correction due date.
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
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 02/20/2025 04:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/20/2025 at 03:16 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that Resident (R1) has an appraisal on file but not current (11/2023) and residents (R2 and R3) did not have an appraisal on file at all which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
1
2
3
4
Facility to submit current and complete Appraisal for R1, R2, and R3 by plan of correction due date, including resident or resident's responsible party's signature and date of receipt by plan of correciton due date.
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that rooms #1 and #3 had pervasive odor of urine which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
1
2
3
4
Facility to submi LIC9098 self-certifying they will ensure that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence by plan of correction due date.
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
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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