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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 02:11:34 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
10/07/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20241007152406
FACILITY NAME:WOODLAND GARDENS SENIOR LIVINGFACILITY NUMBER:
576804194
ADMINISTRATOR:PAZ, DIANAFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: 68DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff do not prevent resident from wandering into residents rooms.
Staff does not assist resident in a timely manner.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conclude a complaint investigation and deliver findings regarding the above allegations. LPA met with Administrator Diana Paz.
The complaint alleges that staff do not prevent resident (R1) from wandering into residents’ rooms. LPA conducted a review of records, interviews, and made observations. Through interviews, LPA discovered that a new resident had been placed in Assisted Living for a respite stay, and it was discovered that resident R1 had unknown behaviors which led to wandering and entering other residents’ rooms. R1 was not re-assessed nor was additional staff dedicated to R1’s supervision for at least two (2) days, therefore the allegation that Staff do not prevent resident from wandering into residents’ rooms is SUBSTANTIATED. Based on LPA’s interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, are being cited on the attached LIC 9099D.”)

Continued on 9099-C....
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 4
Control Number 21-AS-20241007152406
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....

The complaint alleges that Staff does not assist resident in a timely manner. LPA reviewed call bell records and interviewed residents and staff. LPA looked at call bell records for 10/05/2024 through 10/07/2024 and found that R2 and R3 had used the call bell system a total of 11 times. The response times were: 2 calls were under 5 minutes, 2 were 5-6 minutes, 2 were within 10-13 minutes, 3 were within 15–17 minutes, 1 was 28.37 minutes, and 1 was 42.38 minutes. Response times over 15 minutes indicate staff did not respond to the care needs of R2 and R3 in a timely manner, therefore the allegation that Staff does not assist resident in a timely manner is substantiated. Based on LPA observations, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. A civil penalty was issued today for $250.00 for repeated citation within 12 months. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted & appeal of 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: 4 of 4
Control Number 21-AS-20241007152406
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
87468.2(a)(1)
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87468.2Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents... shall have all of the following personal rights: (1)To have a reasonable level of personal privacy in accommodations... conversations, use of the Internet, and meetings of resident and family groups.
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Administrator will submit a plan on how they will ensure that thorough assessments are completed prior to residents moving in, either permanently or as a respite, by completing all pre-assessments and interviews prior to new residents moving in.
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This requirement is not met as evidenced by: Based on interview of R2 LPA found resident R2 and R3 were not allowed personal privacy due to resident R1 wandering about the facility and accessing their room on more than one occasion due to lack of supervision of the resident R1.

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 Administrator to submit plan to LPA by 11/27/2024.
Deficiency Dismissed
Type A
11/26/2024
Section Cited
CCR
87411(a)
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Personnel Requirements -General. (a) Facility personnel shall at all times be sufficient... provide the services necessary to meet resident needs***Based upon records reviewed and interviews conducted, this requirement has not been met as evidenced by:
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**Amended***
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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R2 states that on numerous occasions in the recent past, staff shortages resulted in call buttons not being answered timely; up to nearly an hour delay. This posed an immediate risk to the health and safety of residents in care.
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 In addition, Administrator will provide proof that staff are trained adequately to ensure resident care needs are met timely. Plan to be submitted to CCL by POC date of 11/27/2024, and proof of training submitted by 12/04/2024 in order to clear the deficiency. This is an amendment of the original report to indicate civil penalty language**
Civil penalty of $250 issued for repeat violation within a 12 month period for regulation87411(a).
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: 3 of 4
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
10/07/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20241007152406

FACILITY NAME:WOODLAND GARDENS SENIOR LIVINGFACILITY NUMBER:
576804194
ADMINISTRATOR:PAZ, DIANAFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Resident’s Call Button in Disrepair
INVESTIGATION FINDINGS:
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The complaint alleges that resident R2's and R3’s call button is in disrepair. LPA conducted an inspection of R2 and R3’s apartment and determined that the call bells in the apartment and the pendant worn by R2 were in working order. Additionally, review of call bell records indicate that the call bells were activated and responded to over the course of 10/05/2024 and 10/07/2024, therefore the allegation that the call buttons are in disrepair is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated
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: 2 of 4