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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200612
Report Date: 06/03/2021
Date Signed: 06/03/2021 12:44:31 PM

Document Has Been Signed on 06/03/2021 12:44 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:WOODLAND HOMEFACILITY NUMBER:
079200612
ADMINISTRATOR:SALDANA, VICKIFACILITY TYPE:
740
ADDRESS:4219 WOODLAND DRIVETELEPHONE:
(510) 287-8488
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 4CENSUS: 4DATE:
06/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Shasta PhillipsTIME COMPLETED:
12:45 PM
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On 06/03/21 at approximately 11:15am Licensing Program Analysts (LPAs) Allison O'Hollaren and Lizette Francisco arrived unannounced to conduct a case management visit to perform a health and safety check of the facility, meeting with Staff Shasta Phillips. LPAs explained the purpose of the visit.

A tour of the interior and exterior of the physical plant was made. The facility is adequately clean and organized. The electricity, gas, and water were all operational. There was adequate 7 days non-perishable and 2 days perishable foods in stock. Residents were adequately groomed and attired. Three staff were present. The room temperature was maintained at 70 degrees Fahrenheit. LPAs measured water temperature at 106 degrees Fahrenheit. Medications were locked in cabinet. Sharp objects were locked in a cabinet.

This report was reviewed with Staff Shasta Phillips and a copy of the report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2021
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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