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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602567
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:23:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2021 and conducted by Evaluator Alyssa Ramirez
COMPLAINT CONTROL NUMBER: 08-AS-20210819121422
FACILITY NAME:WOODLAND GARDEN RESIDENTIAL CARE IIFACILITY NUMBER:
374602567
ADMINISTRATOR:BENITO ENCABOFACILITY TYPE:
740
ADDRESS:1709 KATY PLACETELEPHONE:
(760) 294-5728
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 5DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Benito EncaboTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility did not following Covid-19 mitigation plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Administrator Benito Encab and discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff and clients

On 8/19/2021, it was reported to CCL that facility did not follow COVID-19 mitigation plan
Regarding the allegation, it was reported that a visitor observed staff not wearing a mask and staff did not take visitor’s temperature before entering the facility.

[Continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20210819121422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: WOODLAND GARDEN RESIDENTIAL CARE II
FACILITY NUMBER: 374602567
VISIT DATE: 12/19/2024
NARRATIVE
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Interviews with facility staff, revealed no concern for facility not following COVID-19 mitigation plan. Interviews with outside sources also reported no concerns in regards to facility not following COVID protocols. A review of records revealed that facility submitted a COVID-19 mitigation plan to the department on 3/19/2021. Plan states that staff are required to wear facial coverings and all visitors must get their temperature checked upon entering facility. The department conducted a case management visit to the facility on 8/24/2021, where LPA Hamer noted that staff were observed without a mask and staff did not check LPA’s temperature upon arrival.

The departments review of the available evidence revealed that the preponderance of evidence standard was met and the allegation was SUBSTANTIATED. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of corrections was developed with Administrator.

An exit interview was conducted with Administrator to whom a copy of this report and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210819121422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: WOODLAND GARDEN RESIDENTIAL CARE II
FACILITY NUMBER: 374602567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2025
Section Cited
CCR
87470(a)
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Infection Control Requirements : A licensee shall ensure that infection control practices are maintained. Based on observation and review of Covid-19 related records, staff did not ensure that infection control practices were maintained.
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Administator will provide a COVID-19 training to all staff and submit proof of training to LPA by training due date.
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This posed a potential health risk to 5 out of 5 residents in care.

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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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3