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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200689
Report Date: 09/14/2021
Date Signed: 09/14/2021 12:10:54 PM

Document Has Been Signed on 09/14/2021 12:10 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WOODSIDE RESIDENTIAL CARE FACILITY FOR ELDERLYFACILITY NUMBER:
019200689
ADMINISTRATOR:MIRRIAM PARASFACILITY TYPE:
740
ADDRESS:20531 FOREST AVENUETELEPHONE:
(510) 538-7262
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 14; 14CENSUS: 11DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Mirriam ParasTIME COMPLETED:
12:15 PM
NARRATIVE
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On 9/14/2021 at 10:55am, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Mirriam Paras and explained the purpose of the visit.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. All hand washing stations were equipped with soap, towels and garbage with a lid. LPA observed food and paper supplies are sufficient. Visitor policy is posted at facility entrance. Common areas are disinfected frequently throughout the day.

During record review, it was confirmed that the facility has a mitigation plan on file.

LPA observed two fire extinguishers last serviced on February 21, 2020.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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 09/14/2021 12:10 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 09/14/2021 at 11:51 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WOODSIDE RESIDENTIAL CARE FACILITY FOR ELDERLY
FACILITY NUMBER: 019200689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed two fire extinguishers that were last serviced February 21, 2020 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2021
Plan of Correction
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By POC date Administrator will have fire extinguisher serviced or replaced, and submit a copy of tag to CCL by fax or email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
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