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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881656
Report Date: 08/11/2025
Date Signed: 08/11/2025 11:34:34 AM

Document Has Been Signed on 08/11/2025 11:34 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WOODCREST GARDEN HOME CARE INCFACILITY NUMBER:
331881656
ADMINISTRATOR/
DIRECTOR:		NOZAWA, MINGCHINFACILITY TYPE:
740
ADDRESS:15600 CHICAGO AVETELEPHONE:
(626) 227-5299
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY: 6CENSUS: 0DATE:
08/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee Mingchin NozawaTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst, (LPA) Armando Perez made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with Applicant, Mingchin Nozawa, who accompanied LPA for the inspection. Applicant has submitted an application for six (6) non ambulatory residents in which one (1) is approved for bedridden. On June 18, 2025, Riverside City Fire Department approved a fire clearance for the facility.

The facility is a one story home with 3 client bedrooms, 1 staff bedroom, 2 bathrooms, laundry room, living room, dining area, kitchen, and attached garage. LPA observed clients’ bedrooms with the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, lighting, and emergency lighting. Client bathrooms and showers had clean appliances that were operating in safe and sanitary condition. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Sharps, such as knives and scissors, will be stored in a locked cabinet in the kitchen.

Client and staff files will be in a locked cabinet in the kitchen. Client medication will be centrally stored and locked in the kitchen cabinet as well. The facility has no pool or any bodies of water. There is a covered patio area with sufficient seating for all the clients. All passageways were free from obstruction. LPA observed 2 charged fire extinguishers in the facility with the next service date of December 31, 2026. Licensee is aware the fire extinguisher must be serviced yearly and has until the end of 2026. The smoke detectors and carbon monoxide alarms are a combined unit and were operational. LPA observed a covered fireplace in the living room area that has the required covering.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Armando Perez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WOODCREST GARDEN HOME CARE INC
FACILITY NUMBER: 331881656
VISIT DATE: 08/11/2025
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The facility does not have any known firearms and ammunition on the property. LPA observed the required postings of the emergency disaster plan, resident personal rights, complaint procedures, employee rights, visitation rights, facility sketch, and the Long-Term Care Ombudsman poster. Facility contains emergency supplies and first aid kits with the required items. The facility has working telephone for client use. LPA observed Applicant's Administrator Certification on file with expiration date of 12/05/2025.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete and this facility has no issues or concerns. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Applicant Mingchin Nozawa.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Armando Perez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC809 (FAS) - (06/04)
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