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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881243
Report Date: 02/25/2022
Date Signed: 02/25/2022 11:40:48 AM


Document Has Been Signed on 02/25/2022 11:40 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ET WOODVILLE MANORFACILITY NUMBER:
331881243
ADMINISTRATOR:MANGENTE, KRISTINEFACILITY TYPE:
740
ADDRESS:2885 ANTARES DRIVETELEPHONE:
(951) 343-1123
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 6DATE:
02/25/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kristine Mangente, LicenseeTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:00 AM, LPA met with Licensee/Administrator Kristine Mangente. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 9/23/21 for a total capacity of four (4) non-ambulatory and two (2) bedridden residents. Fire clearance was granted on 11/16/2021. LPA Delgado observed the following:
Structure:
Facility was a one-story house with five (5) resident bedrooms, two (2) resident bathrooms, living room, family room, dining area and kitchen. There was an attached one car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #1, #2, #3 and #4 will accommodate any non-ambulatory resident, bedroom #5 will accommodate bedridden residents. 5 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 9:41 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.3 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
(CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-0337
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ET WOODVILLE MANOR
FACILITY NUMBER: 331881243
VISIT DATE: 02/25/2022
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(CONTINUED FROM LIC 809)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the garage. Laundry detergents and cleaning supplies were observed in garage away from residents.
Living/Family room:
There was a living/family room with for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio table and two chairs were observed in the backyard; more chairs are needed. There was a gate on the South side and North side of the property with a self-latching from the exterior doors that needs to be repaired. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway. Obudsman poster and Let-Us-No poster observed.
General items:
One (1) fire extinguishers were charged and located in the kitchen. Seven (7) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order except for one (1) in the living room. Client records will be stored in a locked cabinet in the Family room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was not observed however the required 72-hour emergency food supply was not discernible from the regular food supply. Component III was completed on this day as well.

(CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-0337
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ET WOODVILLE MANOR
FACILITY NUMBER: 331881243
VISIT DATE: 02/25/2022
NARRATIVE
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(CONTINUED FROM LIC 809C)

Pre-Licensing is incomplete and the following corrections to be resolved by 2/28/2022:


obtain a separate 72-hour emergency food supply
obtain separate emergency water
obtain and post visiting policy
obtain 30-Days of PPE supplies
obtain additional patio chairs
obtain auditory alarm for live-in staff quarters
remove debris in the backyard
repair smoke detector in the Living room

An exit interview was conducted, and a copy of this report was given.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-0337
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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