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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804124
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:30:25 PM

Document Has Been Signed on 03/20/2025 03:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WOODWARD ASSISTED LIVINGFACILITY NUMBER:
496804124
ADMINISTRATOR/
DIRECTOR:		TADURAN, GLORIAFACILITY TYPE:
740
ADDRESS:1825 WOODWARD DRTELEPHONE:
(707) 843-7268
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 6DATE:
03/20/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:59 PM
MET WITH:Gloria Tadrun, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a POC visit and was greeted by caregiver, LVN. Facility Administrator Gloria Tadrun arrived later.

On 2/20/25 LPA conducted the facility annual inspection and issued citations for deficiencies of the following regulations: HSC 1569.618(c)(3), HSC 1569.625(b)(2), CCR 87625(b)(3), CCR 87355(e)(3), CCR 87555(b)(27), CCR 87463(i), CCR 87412(g) and CCR 87202(a). As of today 3/20/25, the plans of corrections for these deficiencies have not been submitted to CCL. Therefore, deficiencies for regulations: HSC 1569.618(c)(3), HSC 1569.625(b)(2, CCR 87625(b)(3), CCR 87355(e)(3), CCR 87555(b)(27), CCR 87463(i), and CCR 87412(g) are being re-cited today.

The plan of correction was due on 2/21/25 for HSC 1569.618(c)(3). The plan of correction required facility to submit plan to have S4 and S2 complete First Aid/CPR training. Training to be completed no later than 3/6/25. Proof of First Aid/CPR certificate/card to be submitted to CCL no later than 3/6/25. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties.

The plan of correction was due on 2/21/25 for HSC 1569.625(b)(2). The plan of correction required facility to submit plan to have all staff complete required number of hours (as identified by their start date) of training by plan of correction due date. Admin agrees to use Senior Community Learning for all staff training. Training certificates in the required number of hours for each respective staff: S1, S2. S3, S4, S5, S6, and S7 to be completed and sent to CCL by no later than 3/13/25. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties.

The plan of correction was due on 2/24/25 for CCR 87625(b)(3). The plan of correction required facility to

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124
VISIT DATE: 03/20/2025
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Continued from 809...

submit LIC9098 self-certifying they will ensure that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties.

The plan of correction was due on 2/24/25 for CCR 87355(e)(3). The plan of correction required facility to submit to CCL facility Guardian roster print out showing S6 as being associated to the facility by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties.

The plan of correction was due on 2/27/25 for CCR 87555(b)(27). The plan of correction required facility to submit to CCL pictures of grout around kitchen sink free of black substances and film by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties.

The plan of correction was due on 2/27/25 for CCR 87463(i). The plan of correction required facility to submit current and complete Appraisal for R1, R2, and R3 by plan of correction due date, including resident or resident's responsible party's signature and date of receipt by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties.

Continued on 809C(2)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124
VISIT DATE: 03/20/2025
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Continued from 809C...

The plan of correction was due on 2/27/25 for CCR 87412(g). The plan of correction required facility to submit Health Screen with TB clearance or LIC503, LIC501, and copy of First Aid/CPR for S6 and S7 to CCL by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties.

Upon arrival today 3/20/25, LPA observed deficiency of regulation CCR 87202(a) has been corrected. LPA observed broken hospital bed has been removed and is no longer partially obstructing the emergency fire exit path. LPA asked caregiver, LVN why facility did not submit pictures of cleared path in order to clear deficiency. Caregiver, LVN explained they did send the picture to the Administrator on 3/5/25. LPA reviewed metadata of picture shown to LPA of removal and it did show the picture was taken 3/5/25. LPA advised next time, be sure to send the picture to CCL to clear the deficiency. LPA advised Administrator of the same. Deficiency is cleared.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/20/2025 03:30 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/20/2025 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
HSC
1569.618(c)(3)

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§1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c)The facility shall employ... a sufficient number of staff members to... (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid
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Facility to submit proof of First Aid/CPR certificate/card tfor S2 and S4 o be submitted to CCL no later than 3/21/25.
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training is on duty and on the premises at all times... This requirement was not met as evidenced by: Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that S2 has expired First Aid/CPR exp 1/10/2025. S4 did not have any CPR/First Aid on file, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
03/21/2025
Section Cited
HSC1569.625(b)(2)

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§1569.625 Staff training; legislative findings; contents (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement is not met as evidenced by: Based on LPA and caregiver, LVN observation and record review the
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Facility to submit plan to have all staff complete required number of hours (as identified by their start date) of training by plan of correciton due date of 3/21/25. Admin agrees to use Senior Community Learning for all staff training. Training certificates issued by Senior Community Learning in the required
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licensee did not comply with the section cited above in that all staff: S1, S2, S3, S4, S5, S6 and S7 did not have required training completed, which poses an immediate health, safety or personal rights risk to persons in care.
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number of hours for each respective staff: S1, S2. S3, S4, S5, S6, and S7 to be completed and sent to CCL by no later than 4/3/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/20/2025 03:30 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/20/2025 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
CCR
87412(g)

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87412 Personnel Records (g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by:Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that S6 and S7 did not have
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Facility to submit Health Screen with TB clearance or LIC503, LIC501, and copy of First Aid/CPR for S6 and S7 to CCL by plan of correction due date of 3/21/25.
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Health Screen, Training, TB, or any paperwork on file, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
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Section Cited
CCR87463(i)

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87463 Reappraisals (i) When there is significant change in condition... or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate
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Facility to submit current and complete Appraisal for R1, R2, and R3 by plan of correction due date, including resident or resident's responsible party's signature and date of receipt by plan of correciton due date.
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facility staff, asspecified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that Resident (R1) has an appraisal on file but not current (11/2023) and residents (R2 and R3) did not have an appraisal on file at all which poses an immediatel health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/20/2025 03:30 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/20/2025 at 02:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
CCR
87355(e)(3)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)...
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Facility to submit to CCL facility Guardian roster print out showing S6 as being associated to the facility by plan of correction due date.
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This requirement is not met as evidenced by:Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that Staff S6 was not associated to the facility, which poses an immeidatel health, safety or personal rights risk to persons in care.
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Type A
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Section Cited
CCR87555(b)(27)

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87555 General Food Service Requirements(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
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Facility to submit plan to have areas around sink free of black substances and film by plan of correction due date. Facility to submit pictures of cleaned kitchen area around kitchen sink free of black substances and film to CCL by no later than 3/28/25.
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Based on LPA and caregiver, LVN observation and record review, the licensee did not comply with the section cited above in that black substance present in grout and spotted film around sink in grout, which poses an immeidate health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/20/2025 03:30 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/20/2025 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODWARD ASSISTED LIVING
FACILITY NUMBER: 496804124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
CCR
87625(b)(3)

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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains
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Facility to submti LIC9098 self-certifying they will ensure that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence by plan of correction due date.
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free of odors from incontinence. This requirement was not met as evidenced by: Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that rooms #1 and #3 had pervasive odor of urine which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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