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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200612
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:40:03 PM

Document Has Been Signed on 01/27/2023 12:40 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WOODLAND HOMEFACILITY NUMBER:
079200612
ADMINISTRATOR:KOORN, CAROLINEFACILITY TYPE:
740
ADDRESS:4219 WOODLAND DRIVETELEPHONE:
(925) 349-5514
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 4CENSUS: 4DATE:
01/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Caroline KoornTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted case management and met with Caroline Koorn.

During the course of investigation, the Department observed:

1. Staff 1 (S1) was not located in LIS – 87411(g)

2. Facility staff failed to provide adequate care to R1 resulting in R1 sustaining pressure injuries - 87468.2

On May 28, 2021, R1 was seen at John Muir Walnut Creek after sustaining a fall resulting in a head injury. Medical records document R1 has a Stage 3 pressure injury on the left buttock and unstageable pressure injury on the mid-spine.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12- month period may result in civil penalties.

Exit interview was conducted with Caroline Koorn and Appeal Rights was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/27/2023 12:40 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/27/2023 at 11:35 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WOODLAND HOME
FACILITY NUMBER: 079200612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/28/2023
Section Cited
CCR
87411(g)(1)

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(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or
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Administrator will review Sec 87411 and submit statement of understanding to CCL by POC date.
An immediate civil penalty of $500 is being assessed for today’s visit.
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Based on record review, the licensee did not comply with the section cited above. The Department observed S1 did not have fingerprint clearance while working at the facility which poses an immediate health and safety risk to the clients under care.
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Request Denied
Type A
01/28/2023
Section Cited
HSC87468.2

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To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse
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A Non-Compliance Conference (NCC) will be scheduled.
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Based on R1’s medical records, Licensee did not comply with section cited above. R1 sustained a Stage 3 pressure injury on the left buttock and unstageable pressure injury on the mid-spine.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023


LIC809 (FAS) - (06/04)
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