502701131-2-10-2022-27-AS-MJEN-CBJ3FE-20220210171236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701131
Report Date: 02/10/2022
Date Signed: 02/10/2022 05:12:43 PM

Document Has Been Signed on 02/10/2022 05:12 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	WOODS BOARD AND CARE LLC		FACILITY NUMBER:	502701131
ADMINISTRATOR:	WOODS, RANDY		FACILITY TYPE:	735
ADDRESS:	2642 TOPEKA STREET		TELEPHONE:	(209) 869-6624
CITY:	RIVERBANK	STATE: CA	ZIP CODE:	95367
CAPACITY: 15		CENSUS: 15	DATE:	02/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jessica Ruiz and Randy Woods		TIME COMPLETED:	05:30 PM

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Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived unannounced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPAs Michael Bilger and Maja Jensen met with Jessica Ruiz and Randy Woods who assisted LPAs in today’s inspection. LPAs explained the purpose of the visit. Upon arrival, LPAs confirmed there are no active COVID cases.

Facility has a fire clearance for 15 ambulatory and 0 non-ambulatory residents. Administrator, Randy Woods and Jessica Ruiz will be the Administrators of this facility. The facility administrator’s certificate #:020845735 and Expires: 11/1/22 for Jessica Ruiz and the facility administrator’s certificate #:6017384735 and Expires: 4/6/22 for Randy Woods.

LPAs inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen.

Physical Plant:

The outdoors of the facility and fire routes were clear of obstructions. The indoors of the facility was observed to be clean and with adequate lighting and furniture. The fire extinguishers were last serviced in August of 2021 and are current. The physical plant temperature was 75 degrees and the water temperature was 110.1 degrees. Night lights were observed throughout. There is no garage on the property.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WOODS BOARD AND CARE LLC	FACILITY NUMBER: 502701131
	VISIT DATE: 02/10/2022

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Food Services: LPAs observed 7 day supply of non-perishable and 2 day supply of perishable food. Fresh fruit and vegetables were available.

Care & Supervision: Toxins and knives are kept locked. There are adequate activities for clients, access to internet and telephone. Linens were adequate in supply. Staffing was observed to be adequate. There is a separate room available for isolation for a COVID if needed.

Records Review: There are 5 staff and two administrators. 2 staff files of 5 were reviewed. First aid certificate and TB test documentation is current. 3 resident files were reviewed and contained all necessary documentation

Administration: Administration certifications, COVID posting, resident rights, "see something, say something" signs were posted in prominent areas.

Medication: Medications were observed to be secured and locked.

The applicant has passed the pre-licensing component of the application process. LPAs will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

Exit Interview was conducted and a Component III presentation was conducted.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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