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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602567
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:18:48 PM

Document Has Been Signed on 12/28/2023 01:18 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WOODLAND GARDEN RESIDENTIAL CARE IIFACILITY NUMBER:
374602567
ADMINISTRATOR:BENITO ENCABOFACILITY TYPE:
740
ADDRESS:1709 KATY PLACETELEPHONE:
(760) 294-5728
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 5DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:ADMINISTRATOR, BENITO ENCABOTIME COMPLETED:
01:25 PM
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On December 28, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Administrator, Benito Encabo. LPA Mixson introduced herself and stated the purpose of the visit. The facility file review was conducted at the office and on site.

LPA Mixson toured the facility along with the Administrator, and observed the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home, located at 1709 Katy Place, Escondido, CA 92026. Physical Plant: The facility phone number is (760) 294-5728 and is operable. The LPA observed the residents bedrooms, they were equipped with required furniture as per Title 22 at the time of this visit. LPA Mixson inspected facility bathrooms and the hot water temperature tested within regulations. The bathrooms were clean and appliances were operating appropriately at the time of today inspection. The LPA observed facility smoke detectors, carbon monoxide alarms, and fire extinguishers, and they are operable. LPA Mixson observed required postings such as (If you See Something, Say Something), the (Ombudsman Poster), and the (Personal Rights). The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There is a designated storage space for the resident and staff files and it was locked and inaccessible to residents. Medications: were reviewed, locked and inaccessible to residents in care. There was a 30 day supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility appliances were operable currently at the time of this visit. Food Service: The facility had the required non-perishable and perishable food items, as per Regulations, and there are a variety of food types available for the residents. Dishes and utensils are in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, currently at the time of this visit there are two staff, and five residents. Records Review: LPA Mixson reviewed two resident files, two staff files, interviewed two staff, and reviewed previous CCL forms. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given to the Administrator, Benito Encabo
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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