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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006186
Report Date: 08/19/2022
Date Signed: 08/19/2022 02:42:12 PM

Document Has Been Signed on 08/19/2022 02:42 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WOODBRIDGE CARE HOME, INC.FACILITY NUMBER:
306006186
ADMINISTRATOR:ALPUERTO, TERESAFACILITY TYPE:
740
ADDRESS:18932 GREEN WILLOW COURTTELEPHONE:
(714) 505-9209
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 5DATE:
08/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Teresa Alpuerto and Francis MallariTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Michelle Reed made an announced visit to the facility for purpose of conducting a Pre-licensing Inspection. LPA arrived at the facility and was greeted and granted entry by Applicant Francis Mallari and Teresa Alpuerto. Teresa Alpuerto will be the designated Administrator. LPA's temperature was checked upon entry and a hand sanitizing station was observed. An application to operate an Adult Residential Care Facility was received on 5/3/22 for a Corporation Change. The facility is vendorized by Regional Center. At the time of visit there were 2 clients present. 2 were at lunch with a staff and 1 was at day program. Client's present were watching a movie.

Structure:
The facility is a one-story home with 6 bedrooms, 3 bathrooms, living room, kitchen and an attached two car garage. 5 of the bedrooms will be for clients and 1 for staff. The staff room is the room closest to the kitchen. LPA observed the Ombudsman and the See Something Say Something poster (PUB 475) posted on the wall in the dining area. LPA observed there are door alarms on the front door and all exit doors. There is a back yard with one exit gate on the side of the house. There is a shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms
All client bedrooms had the required furnishings. LPA observed all client beds with appropriate linens and blankets. LPA observed all windows were screened.

Toxins:
Toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in a supply closet in the garage. Sharps were also locked.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WOODBRIDGE CARE HOME, INC.
FACILITY NUMBER: 306006186
VISIT DATE: 08/19/2022
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet.

Pool/Jacuzzi:
No bodies of water

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has games and movies for client use. Client's also go out to lunch, visit with family and attend day program

Fire clearance:
Approved by Orange County Fire Authority on 6/2/22.

Component III:
Conducted at the Pre-Licensing visit, information provided on compliance and reporting requirements.

Bedrooms Staff:


Live in staff room

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Grab bars and shower mat were also observed. Hot water measured at 114 degrees F
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WOODBRIDGE CARE HOME, INC.
FACILITY NUMBER: 306006186
VISIT DATE: 08/19/2022
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Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review with the emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible. Emergency water, food and back packs for clients were present.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas stove with 1 oven, 2 refrigerators, dish washer, microwave, washer, and dryer are operational.

No Corrections needed.

The Applicant was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. LPA informed that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure.

Exit interview was conducted and a copy of this report was provided to Applicant Francis Mallari..

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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