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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320101
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:50:12 PM

Document Has Been Signed on 01/26/2023 03:50 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
EL SEGUNDO, 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: 6DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ingrid Morales CaregiverTIME COMPLETED:
04:06 PM
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Ingrid Morales Caregiver, the purpose of today’s visit was explained.

There are currently (6) residents in the facility. (0) residents are ambulatory, (5) are non-ambulatory, (1) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (4) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and attached 2 garage.LPA and Ingrid Morales caregiver and later Benito Laserna, toured the entire facility inside and out. Documents are posted as mandated. Bedrooms are occupied by residents and contain the mandated furniture two of the bedrooms are shared. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is (115.5) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and some residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area available facility has internet for residents use. Resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted. Staff has not N95 fit tested since 2021 therefore a technical assistance was issued.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Benito Laserna, Administrator and a hard copy of report provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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