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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320101
Report Date: 01/14/2022
Date Signed: 01/14/2022 03:58:43 PM

Document Has Been Signed on 01/14/2022 03:58 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WOODBURY GUEST HOMEFACILITY NUMBER:
198320101
ADMINISTRATOR:GALLIOS, WILLIAM V. IIFACILITY TYPE:
740
ADDRESS:1586 WOODBURY DRIVETELEPHONE:
(310) 533-1131
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 5DATE:
01/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Adminstrator - Benito LasernaTIME COMPLETED:
03:00 PM
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On 01/14/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Benito Laserna and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly non-ambulatory residents ages 60 and above. Facility is approved for one (1) bedridden and has a hospice wavier for one (1) residents.


The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) bathrooms, two (2) living areas, dining area, office area, kitchen, staff room and outside covered patio area with a table and chairs. There is an attached garage with access only through the garage door used for storage. The garage consists of the washer and dryer for laundry and a second refrigerator and freezer.


LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 105.4 F and 108.5 F in the bathrooms and kitchen. A comfortable temperature was maintained in the facility.


Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WOODBURY GUEST HOME
FACILITY NUMBER: 198320101
VISIT DATE: 01/14/2022
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Two (2) fire extinguishers were fully charged next to the kitchen and in the garage, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate. First aid kit available is available in the office area.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings. All mandated inspection control posters were posted.


Three Advisory Notes - Technical Assistance were issued, please see LIC9102-AN.

No deficiencies were cited during the visit.

An exit interview was conducted, and a copy of this report was provided to Administrator Benito Laserna.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
LIC809 (FAS) - (06/04)
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