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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200612
Report Date: 02/21/2023
Date Signed: 03/20/2023 03:57:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210521161120
FACILITY NAME:WOODLAND HOMEFACILITY NUMBER:
079200612
ADMINISTRATOR:SALDANA, VICKIFACILITY TYPE:
740
ADDRESS:4219 WOODLAND DRIVETELEPHONE:
(510) 287-8488
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:4CENSUS: 4DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Carolyn Koorn, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident sustained injuries while in care
INVESTIGATION FINDINGS:
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This is an amendment to an original 9099 dated 2/21/2023
On 03/20/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator (ADM) to amend the finding of above allegation due to additional information received. LPA explained the purpose of the visit with ADM.

Allegation: Resident sustained injuries while in care
Investigation Finding: Unsubstantiated
On 02/24/23, the Department interviewed the staff (ADM, W1) who confirmed that resident (R1) was taken to the hospital on 05/16/21 due to an altered level of consciousness and suspected possible seizure. The Department reviewed R1’s hospital records dated 5/16/21 thru 5/22/21 which showed R1 had no pressure injuries noted upon admission. While at the hospital on 05/18/21, ER nurse reported unstageable pressure injuries found on R1’s leg and ankle with a primary diagnosis of pulmonary embolism. The Department interviewed staff (ADM, W1) on 02/24/23 who confirmed with LPA that R1 developed the pressure injuries while in care at the hospital on 05/18/21.
Based on records review, interviews conducted and observations made, the Department has investigated the above allegation and found that it is unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident sustained injuries while in care did occur.

Exit interview conducted and a copy of this report provided.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20210521161120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WOODLAND HOME
FACILITY NUMBER: 079200612
VISIT DATE: 02/21/2023
NARRATIVE
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While at the hospital and upon presentation, ER nurse also reported unstageable pressure injuries found on R1’s leg and ankle. Detailed wound care instructions, a home health (wound care) referral and a set of moon booties were sent with R1 to the facility. Wound care nurse visits were scheduled weekly at the facility and the wounds mostly healed. The preponderance of evidence has been met. Therefore, the allegation that resident sustained injuries while in care is substantiated.

Immediate civil penalty of $500 is being assessed on today’s visit.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20210521161120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WOODLAND HOME
FACILITY NUMBER: 079200612
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2023
Section Cited
CCR
87463(a)(3)
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The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to (3) Any illness, injury, trauma, or change in the health care needs of the resident ...
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An immediate civil penalty of $500 is being assessed for today’s visit.

A Non-Compliance Conference (NCC) will be scheduled.
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This requirement was not met when resident sustained unstageable pressure injuries while in care which posed an immediate health & safety risk to resident in care.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3