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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602567
Report Date: 06/07/2024
Date Signed: 06/07/2024 02:26:55 PM


Document Has Been Signed on 06/07/2024 02:26 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:WOODLAND GARDEN RESIDENTIAL CARE IIFACILITY NUMBER:
374602567
ADMINISTRATOR:BENITO ENCABOFACILITY TYPE:
740
ADDRESS:1709 KATY PLACETELEPHONE:
(760) 294-5728
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 6DATE:
06/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Benito Encabo, AdministratorTIME COMPLETED:
02:40 PM
NARRATIVE
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On today's date 06/07/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to follow up on an Unusual/Injury report and SOC341 that was received reporting sexual abuse regarding Resident #1 (R1). LPA met with Administrator Benito Encabo and explained the purpose of the visit.

LPA conducted a tour of the facility, there were no health and safety concerns observed. The facility had operable utilities, and an adequate food supply. LPA conducted a review of staff and resident files. R1s file review revealed that the department was not notified of R1s death. LPA conducted an interview with Administrator Benito Encabo and verified the dates of the incident (6/6/22) which revealed that the incident was not reported to the department. A deficiency will be cited on the attached 809 for failure to follow reporting requirements.

In addition LPA conducted a facility file review which revealed that the facility has unpaid annual fees of $742.00, that was due on or before 12/17/23. a deficiency will be cited on the attached 809. During the visit LPA provided Administrator with the PIN to pay the fees electronically.

Based on today's case management incident visit a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, LIC 811-Confidential names list, LIC9098-Proof of Corrections form and appeal rights were provided to Benito Encabo, Administrator.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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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Document Has Been Signed on 06/07/2024 02:26 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: WOODLAND GARDEN RESIDENTIAL CARE II
FACILITY NUMBER: 374602567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
87211(a)(1)(A)

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(a) Each licensee shall furnish to the licensing agency reports as the Department may require, including, but not limited to... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurence from any
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The licensee agrees to conduct an in service on reporting requirements. Proof of POC (sign in sheet) is to be submitted to the department by 5pm on the due date (6/21/24) indicated.
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cause regardless of where the death occurred...This requirement is not met as evidenced by R1's death not being reported to the dept. This posed a potential health, safety, and personal rights risk to persons in care.
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Type B
06/21/2024
Section Cited
HSC1569.185

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Health and Safety Code section 1569.185 provides: (a) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be
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The licensee agrees to pay the outstanding annual fees of $742.00. Proof of POC (receipt) is to be submitted to the department by 5pm on the due date (6/21/24) indicated.
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charged by the department annually on each anniversary of the effective date of the license. This requirment is not met as evidenced by: the annual fees were not paid by the due date of 12/17/23. This poses a potential health, safety and personal rights risk to persons in care.
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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: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2