502701131-3-19-2024-27-AS-CYAG-D3HMB6-20240319092724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701131
Report Date: 03/15/2024
Date Signed: 03/19/2024 09:27:32 AM

Document Has Been Signed on 03/19/2024 09:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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:	03/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jessica Ruiz		TIME COMPLETED:	02:00 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	Unannounced Annual visit made out to this facility on 03/15/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Jessica Ruiz. A brief interview was conducted with the facility designated Administrator at this time. This facility was not vendorized at this time to accept and retain any regional center clients at this time. Current census was 15 residents. It was learned that there weren't any residents under the care of hospice at this time. It was learned that there weren't any residents diagnosed with dementia at this time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Jessica Ruiz. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 11/01/2024 with certificate # 6020845735. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet and supplies, located in the facility office room, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WOODS BOARD AND CARE LLC	FACILITY NUMBER: 502701131
	VISIT DATE: 03/15/2024

NARRATIVE

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Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 11/16/2023 by the local fire extinguisher company, Nor-Cal Fire Inc, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (5) facility resident records was conducted and noted on the following LIC 858 form.
A review of (5) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/19/2024 09:27 AM - It Cannot Be Edited

Created By: Charlie Yang On 03/15/2024 at 01:45 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WOODS BOARD AND CARE LLC	FACILITY NUMBER: 502701131
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). 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 [1] out of [5] facility personnel files did not have proper TB clearance by a licensed medical professional which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2024
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all facility personnel files will be reviewed. Any, and all, facility personnel files will be updated to contain the proper TB clearance by a licensed medical professional. A statement of correction, along with proof of updated TB clearance for all facility personnel, will be completed and submitted into CCL by the due date.

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:

Liza King

LICENSING EVALUATOR NAME:

Charlie Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

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