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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200612
Report Date: 12/21/2023
Date Signed: 12/21/2023 11:39:18 AM


Document Has Been Signed on 12/21/2023 11:39 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WOODLAND HOMEFACILITY NUMBER:
079200612
ADMINISTRATOR:SALDANA, VICKI LFACILITY TYPE:
740
ADDRESS:4219 WOODLAND DRIVETELEPHONE:
(925) 349-5514
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:4CENSUS: 4DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alexandria Jackson, Lead Staff
Angelica Bonuan, Administrator 		TIME COMPLETED:
11:45 AM
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On 12/21/2023 at 9:00 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Lead Staff, Alexandria Jackson and explained the purpose of the visit. Administrator arrived at 9:38 AM. The facility’s fire clearance was approved for 4 Non-Ambulatory.
LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which all 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. First aid kit was observed to be complete. Fire extinguisher was last serviced on 05/18/2023. Fire drill was last conducted on 12/05/2023.

At 9:20 AM, LPA reviewed 4 of 4 residents records. At 10:25 AM, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. At 11:17 AM, LPA reviewed a sample of 4 of 4 resident’s medications.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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