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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412265
Report Date: 02/16/2024
Date Signed: 02/16/2024 03:10:23 PM


Document Has Been Signed on 02/16/2024 03:10 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:WOODVILLE MANORFACILITY NUMBER:
336412265
ADMINISTRATOR:MICHAEL PETROIFACILITY TYPE:
740
ADDRESS:2830 ANTARES DRIVETELEPHONE:
(951) 343-0683
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 4DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Licensee - Luminita PetroiTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Licensee Luminita Petroi, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and four (4) residents present. The facility is licensed for six (6) residents, whom may be non-ambulatory, with one (1) who may be bedridden. The facility has a hospice waiver for four (4) 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 stored and inaccessible to clients. The sharp and dangerous objects were observed to be 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 114.7 F. 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.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WOODVILLE MANOR
FACILITY NUMBER: 336412265
VISIT DATE: 02/16/2024
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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. Four (4) resident files were reviewed, and possessed all required paperwork. The listed administrator possesses a current administrator's certificate.

Resident medication was centrally stored and locked in a cabinet in the dining room area. LPA reviewed medications for two (2) residents and found all medication listed on MARs and all required labeling was found to be in place.

LPA reviewed the facility's emergency and disaster plan. 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.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report and technical assistance LIC 9102 was provided to Licensee Luminita Petroi
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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