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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200556
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:31:36 PM

Document Has Been Signed on 06/23/2021 04:31 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 PLACE LLCFACILITY NUMBER:
079200556
ADMINISTRATOR:SALALILA, IAN FREDERICK CFACILITY TYPE:
740
ADDRESS:1795 WOODSIDE COURTTELEPHONE:
(510) 331-1878
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 6CENSUS: 5DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:TIME COMPLETED:
05:00 PM
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On 6/23/2021, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with staff Hazel Karingal and informed the purpose of visit, while conducting facility tour, Administrator Ian Frederick Salalila joined LPA on facility tour. Facility has census of 5.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. Facility has enough supplies of paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.

Facility has enough 2-day perishable food and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan.


.....Continued to LIC809C....
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WOODSIDE PLACE LLC
FACILITY NUMBER: 079200556
VISIT DATE: 06/23/2021
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LPA observed the following:

Licensee has not provided all staff with fit testing for N95 respirators- Administrator will order fit testing kit for the facility, Administrator will send proof of training to LPA by July 9, 2021.

Routine symptom screening (+/- temperature and symptom check) has been NOT initiated at entry for all staff, residents, and visitor . – Administrator will create a binder that will document routine covid19 screening questions for all staff, residents and visitors.

Facility does NOT documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread of infection. - Administrator will create a binder to document daily temperature screening questions for all staff & residents.

A sign-in policy has NOT been enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing) - Administrator will create a binder for sign- in policy using covid19 screening questions for all staff, residents and visitors.

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.



Deficiencies and plan and proof of corrections were discussed with Administrator Ian Frederick Salalia.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2021 04:31 PM - It Cannot Be Edited


Created By: Leslie Ibo On 06/23/2021 at 04:11 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WOODSIDE PLACE LLC
FACILITY NUMBER: 079200556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above routine symptom screening (+/- temperature and symptom check) has been NOT initiated at entry for all staff, residents, and visitor ,facility does NOT documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility, a sign-in policy has NOT been enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing)
which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 07/09/2021
Plan of Correction
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Administrator will create a binder for covid19 screening for staff, residents & visitors. Facility will also create a binder for Covid19 questions to monitor resdients and staffs covid19 symptoms.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
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