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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701131
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:42:51 PM

Document Has Been Signed on 02/24/2023 03:42 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 LLCFACILITY NUMBER:
502701131
ADMINISTRATOR:WOODS, RANDYFACILITY TYPE:
735
ADDRESS:2642 TOPEKA STREETTELEPHONE:
(209) 869-6624
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 15CENSUS: 14DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jessica RuizTIME COMPLETED:
04:00 PM
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On 2/24/23 at 1pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with Administrator Jessica Ruiz and explained the purpose of today's visit. Jessica holds current Administrator certificate # 6020845735 which is good through 11/1/24.

LPA Jensen toured the grounds and interior of the facility. The facility was observed to be clean and free of odor. There was adequate lighting and furniture throughout the facility for the comfort of residents. The thermostat was set at 71 degrees for the comfort of the residents. The carbon monoxide detectors were tested and determined to be in good repair. The fire extinguishers were last serviced in December of 2022 and are in compliance. The facility maintains an emergency food supply and a 30 day supply of PPE. The facility maintains a 1st aid kit that is complete with scissors, tweezers, thermometer, 1st aid manual and wound dressing.

The facility maintains a 2 day supply of perishable food and 7 day supply of non-perishable food. All food that is taken out of the original container is labeled with expiration dates. All vents and the kitchen hood was observed to be sanitary and free of debris. All knives, chemicals and medications were observed to be locked and inaccessible to residents in care.

The resident bedrooms were observed to be adequately furnished. There were night lights observed in the hallways. The facility maintains emergency lighting. LPA Jensen observed 3 disposable razors in a dresser drawer of double occupancy bedroom. The Administrator removed the razors in the presence if the LPA and advised that razors are centrally stored and locked to be provided upon request and returned after use.

Continued on LIC 809C...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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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: 02/24/2023
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Continued from LIC 809....

The facility uses an electronic Medication Administration Records system. The facility was noted to document the effectiveness of PRN medication.

LPA Jensen reviewed 2 staff files and determined they were complete and in compliance. All staff present was verified as being finger print cleared and associated to the facility.

The grounds were observed to be maintained and free of debris. All paths outdoors were determined to be free of obstruction. There is adequate furniture and shade outdoors for resident activities.

A deficiency is being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report was provided with appeal rights.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 03:42 PM - It Cannot Be Edited


Created By: Maja Jensen On 02/24/2023 at 03:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WOODS BOARD AND CARE LLC
FACILITY NUMBER: 502701131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above due to 3 disposable razors stored in a resident's personal dresser which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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The Licensee immediately removed the razors and will submit a written plan to ensure residents do not retain any items that can be hazardous to themselves or others while still maintaining resident personal rights. The Plan shall be emailed to maja.jensen@dss.ca.gov by the plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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