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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881243
Report Date: 03/11/2024
Date Signed: 03/11/2024 12:40:56 PM


Document Has Been Signed on 03/11/2024 12:40 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
RIVERSIDE ASC, 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:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Kristine Mangente - AdministratorTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Administrator Kristine Mangente, who was informed of the purpose of the visit. At the time of the visit there was three (3) staff and six (6) residents present. The facility is licensed for six (6) non-ambulatory residents, of which two (2) may be bedridden. The facility has a hospice waiver for six (6) residents. A dementia program is also on file. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were locked and inaccessible to residents. The sharp and dangerous objects was locked and inaccessible to residents. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 108 degree F, which met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed three (3) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Six (6) resident files were reviewed, and possessed all required paperwork that included Admissions Agreement, Physicians Report, and Needs and Service Plan. The listed administrator possesses a current administrator's certificate.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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 5


Document Has Been Signed on 03/11/2024 12:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ET WOODVILLE MANOR
FACILITY NUMBER: 331881243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in ensuring the centrally stored medication be locked an inaccessible to clients in care for six (6) out of six (6) reisdents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee will ensure medication cabinet is locked and inaccessible to residents in care. Licensee will conduct staff training on Title 22 regulation section 87465 to ensure Licensee and staff are trained and understand the regulation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ET WOODVILLE MANOR
FACILITY NUMBER: 331881243
VISIT DATE: 03/11/2024
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LPA observed the centrally stored medication cabinet to be unlocked and accessible to residents in care. A deficiency cited under Title 22 Regulation 87465(h)(2) Incidental Medical and Dental will be issued along with a plan of correction. LPA reviewed medications for six (6) residents and found medication listed on MARs was found to be in place.

LPA reviewed the facility's emergency and disaster plan. A technical assistance (TA) will be issued under Healthy and Safety Code 1569.695(c) due to quarterly fire drill required to be conducted by the end of the March 2024. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items. Fire extinguishers were fully charged and inspected.

An exit interview was conducted where a copy of this report, LIC 809-D, and appeal rights was provided to Mangente.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5