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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201325
Report Date: 10/18/2024
Date Signed: 10/18/2024 09:49:12 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
09/12/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240912154214
FACILITY NAME:WOODLANDS IVFACILITY NUMBER:
079201325
ADMINISTRATOR:CHAUDHRY, TAYYABAFACILITY TYPE:
740
ADDRESS:3292 WALNUT LNTELEPHONE:
(925) 433-6000
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 3DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Cathia Sheryll DelgadoTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident neglected while in care
Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/20/2024 at 9:00AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the allegations listed. LPA explained the purpose of the visit to Caregiver, Cathia Sheryll Delgado. Administrator was unable to attend and approved caregiver to sign report over the phone.

During the course of the investigation LPA interviewed 2 staff as well as spoke with medical staff (MS) associated to R1. S1 and S2 both stated that R1 would hit themselves on the wheel chair, try to jump through windows, hit doors, and hurt thyself with the accessories thereby leading to bruises. Medical staff stated that R1 has behavioral concerns and that they have been seen for on numerous occasions by the Psychiatric team. MS also noted that R1 acts out and gets aggressive and violent because they do not want to be in a RCFE. Based on the interviews of facility staff and medical staff both allegations are UNSUBSTANSIATED

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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