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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 576804194
Report Date: 11/26/2024
Date Signed: 11/26/2024 02:57:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240911105628
FACILITY NAME:WOODLAND GARDENS SENIOR LIVINGFACILITY NUMBER:
576804194
ADMINISTRATOR:LAUREN ANDERSENFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: 68DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not ensure residents are changed out of soiled clothing in a timely manner
Staff do not ensure transportation arrangements are provided to residents in care

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an investigation and deliver findings regarding the above allegations.

LPA reviewed documents, conducted interviews and made observations. The complaint alleges that staff do not ensure transportation arrangements are provided to residents in care. LPA interviewed resident R1 who had an appointment on 9/10/24 but due to transportation errors the resident was transported to wrong address and missed their appointment. R1 reported to LPA that a new appointment was made for 9/18/24 but due to staff not following up with R1 ensuring new appointment and transportation were scheduled that appointment was missed as well. Missed appointments resulted in R1 being sent to Emergency Department via ambulance for emergency wound care (see photo). Therefore the allegation that staff do not ensure transportation arrangements are provided to residents in care is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 21-AS-20240911105628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODLAND GARDENS SENIOR LIVING
FACILITY NUMBER: 576804194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/26/2024
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(2)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.



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Administrator to provide plan that will ensure resident transportation needs are met to CCL by 11/27/2024.
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This requirement was not met as evidenced by: Based on LPA’s interview with R1 the Administrator did not make arrangements or provideadequate transportation assistance for R1, which led to emergency treatment via ambulance.

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Deficiency Dismissed
Type A
11/26/2024
Section Cited
CCR
87411
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87411Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs***Based upon records reviewed and interviews conducted, this requirement has not been met as evidenced by:
A review of call bell records show that response times were delayed up to 1 hour. This poses an immediate risk to the health and safety of residents in care.
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Administration to provide a written plan that outlines protocols going forward that will guarantee that sufficient staff are on duty to ensure that all residents' needs are met timely.
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Plan to be submitted to CCL by POC date of 11/27/2024 to clear the deficiency.
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: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240911105628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WOODLAND GARDENS SENIOR LIVING
FACILITY NUMBER: 576804194
VISIT DATE: 11/26/2024
NARRATIVE
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Continued from 9099....

.A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency was cited on 9099-D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.

It is alleged that Staff do not ensure residents are changed out of soiled clothing in a timely manner. LPA toured the facility and residents in Assisted Living to be clean and dressed appropriately. Observations of residents in memory care found them to be clean; and resident preferences for attire respected. Call bell records for Assisted Living for 09/7/2024 through 09/10/2024 showed approximately 387 call bells pressed in Assisted Living with approximately 83 call bells that took over 15 minutes to clear; 1 response took over an hour, another over 2 hours and one over 3 hours before call bell was cleared. Although 66% of the call bells were answered in 10 minutes or less on the 3 days studied, 21% were not therefore the allegation that staff do not ensure residents are changed out of soiled clothing in a timely manner is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is being cited on 9099-D.

**Civil penalty in the amount of $250.00 has been assessed on this date for a repeat violation in the past 12 months for regulation 87411(a) on 03/21/2024.



Deficiencies are cited from the California Code of Regulations (CCRs), Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3