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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701131
Report Date: 06/27/2022
Date Signed: 06/27/2022 04:34:10 PM

Document Has Been Signed on 06/27/2022 04:34 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: DATE:
06/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Randy Woods and Jessica RuizTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a POST LICENSING visit. LPA Jensen met with Jessica Ruiz and Randy Woods and explained the purpose of today's visit.

LPA Jensen toured the facility and the grounds including but not limited to dining room, living room, all resident bedrooms, kitchen and smoking area. The facility was observed to be clean, free of odor and adequately furnished. The temperature in the facility was set at 78 degrees which falls within the required regulatory range of 68-85 degrees. The water temperature in the resident bathroom was 107.2 which falls within the required regulatory range of 105-120 degrees. The fire alarm and carbon monoxide detectors were observed to be in good repair. The fire extinguishers were last serviced on 8/20/21 and are in compliance. The facility's emergency disaster plan was reviewed and is in compliance. The grounds were observed to be well maintained and free of debris with clear exit paths.

LPA Jensen reviewed a staff file and a resident file which were both observed to be complete and well organized. The staff file was observed to have training records well documented the amount of training was observed to be in excess of regulatory requirements. The staff CPR certification was current. The P&I ledgers were reviewed and observed to be consistent and complete. The MAR for resident 1 was observed to be consistent and complete.

The facility was observed to have in excess of a 2 day supply of perishable food and a 7 day supply of non- perishable food. The refrigerator and freezers were observed to be clean and clear of debris. A supply of PPE in excess was observed to be available on site. The first aid kits were observed to be complete.

The staff on duty were verified to be fingerprint cleared and having met all training requirements.

Continued on 809-C............
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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: 06/27/2022
NARRATIVE
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The medications were observed to be locked and inaccessible to residents.

As a result of today's visit deficiencies were cited on the corresponding LIC 809-D. An exit interview was conducted and a copy of this report and appeal rights was given to Administrator Jessica Ruiz.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2022 04:34 PM - It Cannot Be Edited


Created By: Maja Jensen On 06/27/2022 at 04:03 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: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2022
Section Cited
CCR
80087(g)

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(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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During the course of the visit the Administrator removed the knives from the accessible kitchen drawer to locked kitchen drawer. LPA Jensen discussed with Administrator that knives cannot be distributed to the client's for their use at meal time. No plan of correction is necessary at this time as the deficiency was corrected in the LPA's presence.
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Based on LP Jensen's observation of steak knives in an unlocked drawer that is accessible to residents.
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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: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022


LIC809 (FAS) - (06/04)
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