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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412425
Report Date: 08/18/2023
Date Signed: 08/18/2023 03:22:27 PM


Document Has Been Signed on 08/18/2023 03:22 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:WINTER WOODS COTTAGESFACILITY NUMBER:
336412425
ADMINISTRATOR:EUFEMIA CACDACFACILITY TYPE:
740
ADDRESS:845 W. LA CADENA DRIVETELEPHONE:
(951) 682-4198
CITY:RIVERSIDESTATE: CAZIP CODE:
92501
CAPACITY:23CENSUS: 17DATE:
08/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eufemia Cacdac, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to address a violation observed during the investigation of complaint #18-AS-20230814143626. The LPA met with Administrator, Eufemia Cacdac, and informed her of the purpose for her visit.

During the investigation it was discovered Resident One (R1) has a Restricted Health Condition (RHC). A file review was conducted and no written agreement between the Licensee and the Home Health Agency providing services for R1's RHC was found. According to the Administrator, a written agreement was created though could not be found during the visit. This poses a potential threat to the health, safety, and personal rights of the resident in care. A citation will be issued.

An exit interview was conducted; this report was reviewed with the Administrator and a copy was provided, along with the LIC 811 and instructions on appeal rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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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Document Has Been Signed on 08/18/2023 03:22 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: WINTER WOODS COTTAGES
FACILITY NUMBER: 336412425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
87609(b)(4)

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ALLOWABLE HEALTH CONDITIONS AND THE USE OF HOME HEALTH AGENCIES: (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee & home health agency agree in writing on the responsibilities of the
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The Administrator stated the original agreement will be submitted to the Department once found. She reported a new agreement will be created if the original is not found.
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HH agency, & those of the licensee in caring for the resident’s medical condition(s). This requirement wasn't met as evidenced by: Based on records review, the Licensee didn't ensure a written agreement was on file. A file review revealed no written agreement between the Licensee & the HH for R1 was found.
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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: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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