Woodbridge Terrace

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff left resident unattended in soaking wet and dirty diapers for extended periods resulting in multiple UTIs Staff mismanged resident's medication Faciltiy lacks management oversight Insufficient staffing to meet residents’ needs

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on 08/14/2023 and the initial 10 day visit was conducted on 08/22/2023 by LPA Tirre. LPA Tirre obtained copies of pertinent documents such as physicians report. LPA Mendivil conducted interviews with staff and residents. Regarding the allegations Staff left resident unattended in soaking wet and dirty diapers for extended periods resulting in multiple UTIs ,Staff mismanged resident's medication, Faciltiy lacks management oversight ,Insufficient staffing to meet residents’ needs the investigation revealed the following: It was alleged that Resident 1 (R1) was left unattended in soaking wet diapers for extended periods of time. Per review of R1's physician report dated 02/20/2023 R1 was diagnosed with Vascular Dementia. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 13, 2025 · control 22-AS-20230814153307

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are mishandling the residents' level of care assessments.

On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Executive Director Christian Otbo and explained the reason for the visit. The Department received the complaint on 09/06/2023 and LPA Mendivil conducted the initial 10 day visit on 09/12/2023. LPA Mendivil interviewed staff and obtained copies of blank assessments. Regarding the allegation that staff are mishandling the resident's level of care assessments, the investigation revealed the following: It was alleged faciltiy is mishandling resident's level of care assessments. Based on interviews with 2 out of 2 staff on 09/12/2023 both staff stated due issues with internal systems they were not able to update assessments electronically, but were providing all services required for each resident. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 29, 2025 · control 22-AS-20230906145516

Allegation investigated: Medication not being administered as prescribed Staff did not treat resident with dignity and respect Facility is charging for services not agreed upon admission

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Executive Director Christian Otbo and explained the reason for the visit. The Department received a complaint on 10/18/2022 and the initial 10 day visit was conducted on 10/25/2022 by LPA Mendivil. During the initial visit LPA Mendivil obtained copies of pertinent documents such as staff schedule, resident assessments and physician reports. LPA Mendivil also interviewed staff and residents. Regarding the allegations medications not being administered as prescribed, staff did not treat resident with dignity and respect and facility is charging for services not agreed upon admission, the investigation revealed the following: It was alleged that Resident 1 (R1) had to wait for over 2.5 hours to receive their medication. CONT on LIC 9099-C dated 05/29/2025 Unsubstantiatedthe state’s words, verbatim · CDSS document, May 29, 2025 · control 22-AS-20221018111730

Allegation investigated: - Staff did not intervene when visitor caused injury to resident

Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegation mentioned above. LPA met with Woodbridge Staff Danna Dsaachs. It was alleged that staff did not intervene when visitor caused injury to the resident. During the investigation LPA interviewed Resident 1 (R1), staff, and witnesses; checked R1’s files; and reviewed R1’s physician report, needs and services plan, identification form and incident reports from the last 3 months of R1. The investigation determined the following: During the investigation LPA asked R1 if their spouse ever hurt them before, R1 denied their spouse hurt them despite being impatient. When asked about the staff at Woodbridge Terrace, R1 replied they were very helpful, great, and provided the care and supervision they needed. Despite R1’s diagnoses and physical limitations, R1 tries to do things independently without any assistance. Witnesses and staff Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 25, 2025 · control 22-AS-20240212114038

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility is accepting bedridden residents, but do not have an approved fire clearance for it. Facility is not adhering to physician reports

This unannounced investigation inspection by Licensing Program Analysts (LPAs) Dwayne Mason Jr. and William Vanegas is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPAs arrived at the facility and were greeted by facility staff. LPAs met with Daizy Gonzalez, Residents Relations Director and explained the nature of the inspection. The department received a complaint on 10/28/2024 stating the facility is accepting bedridden residents, but do not have an approved fire clearance for it and that the facility is not adhering to physician 's reports. During the investigation, the Department interviewed staff and residents in care. (continued on LIC9099-C) Unfoundedthe state’s words, verbatim · CDSS document, Nov 5, 2024 · control 22-AS-20241028120627

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff refused to transport resident for doctors visit. Staff did not prevent covid outbreak.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA met with Assistant Administrator Susie Mora and explained the reason for the visit. The investigation into the allegation, staff refused to transport resident for doctors visit, revealed the following. It was alleged that Resident 1 (R1) complained about an ongoing cough from July 8, through July 13, 2024, and asked staff to assist them with seeing a doctor about their cough. R1 reported they did have a cough but they did not report to staff that they wanted to see a doctor. 5 out of 5 staff interviewed reported they did not notice R1 coughing or displaying symptoms of Covid-19. It was reported that R1's family requested a Covid-19 test for R1 on July 12, 2024 but staff did not administer a Covid-19 test. 5 out of 5 staff interviewed could not corroborate that report. On July 15, 2024 R1 tested positive for Covthe state’s words, verbatim · CDSS document, Jul 25, 2024 · control 22-AS-20240716153403

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff handled resident in a rough manner.

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Memory Care Director Susie Mora and explained the reason for the visit. The department received a complaint on 08/25/2023 and the initial 10 day visit was conducted on 08/31/2023 by LPA Mendivil. During the visit on 08/31/2023 LPA Mendivil obtained copies of pertinent documents including needs and services plan, physician’s report, and behavioral assessment. Regarding the allegation staff handled resident in a rough manner, the investigation revealed the following: It was reported by a witness that Resident 1 (R1) was observed with bruises on hip and thighs while they were being assessed for a new facility. Based on R1’s physician report dated 02/20/2023 it was noted that R1 does not require continuous bed care and is able to ambulate with a walker. CONT on LIC 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 29, 2023 · control 22-AS-20230825114411

Allegation investigated: Facility did not ensure residents receive their medications Facility did not secure medication from residents in care

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Susie Mora, Assistant Executive Director/Memory Care Director and explained the reason for the visit. The department received a complaint on 09/22/2023 and LPA Mendivil conducted the initial visit on 09/29/2023. During the visit LPA interviewed staff and residents and obtained copies of pertinent documents including: medication records and staff training records. Regarding the allegations facility did not ensure residents receive their medications and facility did not secure medication from residents in care, the investigation revealed the following: It was alleged on 08/16/2023, 08/17/2023 and 08/20/2023 that 5 residents did not receive their medications. Based on interviews with Memory Care Director/Assitant Executive Director Susie Mora, the missed medication issue was brought to her attention on or aroundthe state’s words, verbatim · CDSS document, Sep 29, 2023 · control 22-AS-20230922134701