336412425-4-4-2024-18-AS-SMAZ-D3ZVPS-20240404163714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336412425
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:37:25 PM

Document Has Been Signed on 04/04/2024 04:37 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 COTTAGES		FACILITY NUMBER:	336412425
ADMINISTRATOR:	EUFEMIA CACDAC		FACILITY TYPE:	740
ADDRESS:	845 W. LA CADENA DRIVE		TELEPHONE:	(951) 682-4198
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92501
CAPACITY:	23	CENSUS: 19	DATE:	04/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Eufemia Cacdac, Administrator		TIME COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Administrator, Eufemia Cacdac. The LPA informed the Administrator of the purpose for the visit. The facility currently has an approved Hospice Waiver for four (4) residents. The inspection included the following: Physical Plant: A tour of the interior and exterior areas of the facility was conducted. There are no bodies of water located on the property. According to Administrator Cacdac, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction. There are grab bars for each toilet and shower used by residents. The facility's carbon monoxide and smoke detectors were tested by the Administrator and were observed to be in operating condition. Food Service: There is a minimum of 2 days of perishable foods and 1 week's supply of non-perishable foods available. The facility's refrigerator was observed to contain food that was not properly stored. The LPA observed ice cream to be stored in the freezer in an uncovered paper cup, cooked rice to be falling out of an unsealed zip lock bag, cooked rice to be stored in an uncovered glass bowl, a cut banana that was uncovered and turning black. According to Administrator Cacdac, the refrigerator inspected by the LPA is used to store staff food; however, no sign was observed to be posted to corroborate her statement. A citation will be issued. Record Review: All staff were observed to have appropriate fingerprint clearances. The LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Proof of Dementia Care, Postural Supports, Restricted Health Conditions, and Hospice Care training was not observed on file for Staff Two (S2). According to Administrator Assistant, Karla Roces, the training has been provided to S2. When S2 was interviewed the staff member

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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: WINTER WOODS COTTAGES	FACILITY NUMBER: 336412425
	VISIT DATE: 04/04/2024

NARRATIVE

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reported the training has been completed; however, it was not done within 12 months. A citation will be issued. The facility appears to be operating within the conditions specified on the license. The LPA was informed there is currently one resident in care who is receiving hospice services. All services requiring specialized skill are being performed by personnel qualified as appropriately skilled professionals. Resident records (5) were reviewed and found to have the required Admission Agreement and Medical Assessments. The LPA reviewed the facility's corporation status; based on the California Secretary of State website, WINTER WOODS HOME CARE FOR ELDERLY LLC is in a suspended status. Per Licensee representative, Edgardo Roces, the LLA has been in a suspended status for about three years. A citation will be issued.

Medication Review: The LPA reviewed resident's medications. The medications were observed to be well organized and inaccessible to unauthorized individuals. Resident's medications appear to be administered per their physician's orders.

An exit interview was conducted with Administrator Cacdac; this report was reviewed, and a copy was provided, along with the LIC 811, and instructions on appeal rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2024 04:37 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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in one out of one staff members, S2, who did not have proof of training. According to Administrator Assistant, Karla Roces, training has been provided to S2 for Dementia Care, Postural Supports, Restricted Health Conditions, and Hospice Care. When S2 was interviewed the staff member reported the training has been completed; however, it was not done within 12 months. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 05/04/2024
	Plan of Correction
1 2 3 4	Administrator Eufemia Cacdac stated the training will be completed for all staff and proof of training for S2 will be submitted to the Department by the POC due date.

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that there was food observed not to be stored in covered containers. The LPA observed food items in the facility's freezer and refrigerator to not be stored properly. The LPA observed ice cream to be stored one freezer in an uncovered paper cup, cooked rice to be falling out of an unsealed zip lock bag, cooked rice to be stored in a uncovered glass bowl, a cut banana that was uncovered and turning black. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	The Administrator stated a sign will be placed on the refrigerator that stores staff food to distinguish which items are intended for resident consumption.

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 Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/06/2024 10:17 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/06/2024 09:35 AM

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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87205(b)

Accountability of Licensee Governing Body

(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the facility's LLC is not active. This poses a potential health, safety and personal rights risk to persons in care. Based on the California Secretary of State, WINTER WOODS HOME CARE FOR ELDERLY LLC is in a suspended status. Per Licensee representative, Edgardo Roces, the LLC has been in a suspended status for about three years.
	POC Due Date: 06/06/2024
	Plan of Correction
1 2 3 4	Licensee representative stated the requirements to reinstate the LLC with the Franchise Tax Board and the California Secretary of State will be completed and proof will be provided by 06/06/2024. He'll report weekly to the Department to provide updates, in addition, to submitting any supportive documents related to reinstating his governing body. Lastly, a written letter to the Department acknowledging a review of Title 22 regulations pertaining to personal rights, governing body, and record keeping shall be submitted by 06/06/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC809 (FAS) - (06/04)

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