<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200689
Report Date: 09/15/2022
Date Signed: 09/15/2022 11:49:08 AM

Document Has Been Signed on 09/15/2022 11:49 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
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: 14CENSUS: 11DATE:
09/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Mirriam Paras, AdminstratorTIME COMPLETED:
11:55 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
On 9/15/2022, during the course of another visit, Licensing Program Analyst ( LPA ) K. Nguyen interviewed staff. Based on the interview, staff (S1) was present at the facility on 9/15/2022 and worked morning shift . Based on the interview with S1 has been working at the facility for about a 6months. LPA conducted records review using guardian system and S1 is not fingerprint cleared from DOJ & FBI.

$500.00 Civil penalty was assessed.

Civil penalty was assessed during today’s visit.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.


Deficiency, plan and proof of correction and civil penalty were discussed with Mirriam Paras.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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 2
Document Has Been Signed on 09/15/2022 11:49 AM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/15/2022 at 11:23 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: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...1) Obtain a California clearance or a criminal record exemption as required by the Department…


This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator states that AD will to inform S1 not to come back at the facility until S1 is fingerprint cleared from DOJ and FBI.

$500.00 Civil penalty was assessed.
8
9
10
11
12
13
14
Based on observation, interview, and record review, the licensee did not comply with the section cited above S1 started working at the facility for 6months , LPA conducted records review using guardian system and S1 is not finger print cleared which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2