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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412265
Report Date: 02/28/2025
Date Signed: 02/28/2025 11:48:05 AM

Document Has Been Signed on 02/28/2025 11:48 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WOODVILLE MANORFACILITY NUMBER:
336412265
ADMINISTRATOR/
DIRECTOR:		MICHAEL PETROIFACILITY TYPE:
740
ADDRESS:2830 ANTARES DRIVETELEPHONE:
(951) 343-0683
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator- Luminita PetroiTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caregiver Javier Castaneda who was informed of the purpose of the visit; Administrator Luminita Petroi arrived soon after. The facility has a fire clearance for six (6) residents age range 60 and over. Facility currently has 3 residents in hospice.

LPA toured the facility and reviewed records. During the tour, LPA observed the facility is made up of a one-story home with five (5) resident bedrooms and two (2) bathrooms, a formal and family living rooms, dining room, kitchen, and attached garage. All resident bedrooms had the required furniture, lighting, and closet storage. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. LPA toured the kitchen and observed the facility has a two-day supply and perishable foods and a seven-day supply of non-perishable foods that were observed to be properly stored and readily available. Knives and sharp instruments were secured in a locked kitchen cabinet. LPA toured the garage and observed a second refrigerator in the garage with additional perishable food. LPA reviewed random resident and staff records. Resident files reviewed had updated Individual Program Plans and signed admission agreement. Staff files reviewed had the Department's required training records and valid first aid/CPR certification and Fingerprint clearances; Administrator's Certificate is dated 07/06/25. LPA reviewed the facility's Fire and Earthquake Drill logs and noted the facility's last fire drill was conducted on 01/25/25. LPA reviewed the physical medications and Medication Administration Record and did not discover any discrepancies. LPA also observed the facility has a storage locked cabinet in the garage filled with additional cleaning solutions, disinfectants, and laundry detergents. LPA also observed additional clean towels, blankets, and linens for the residents stored in the hallway cabinet next to the bedrooms.
Tricia DanielsonTELEPHONE: (951) -202-5067
Debbie PalaciosTELEPHONE: (951) 248-2222
DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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 2
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: WOODVILLE MANOR
FACILITY NUMBER: 336412265
VISIT DATE: 02/28/2025
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Administrator tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed one (1) charged fire extinguisher mounted in the kitchen near the dining room last serviced on 11/22/24. Medications are secured in a locked cabinet stored near the dinning room area. Exit signs, emergency contact information, resident's personal rights, and complaint information are visibly posted in the dining room wall.

During today's visit, LPA did not issue any citations. An exit interview was conducted and a copy of this report was reviewed and provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) -202-5067
LICENSING EVALUATOR NAME: Debbie PalaciosTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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