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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 02:33:37 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
10/09/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20241009090125
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:
12:12 PM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
02:32 PM
ALLEGATION(S):
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Staff do not ensure residents receive bathing services
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conclude the complaint investigation regarding the above allegation and to deliver findings. LPA met with the Administrator Diana Paz.

The complaint alleges that Staff do not ensure residents receive bathing services. During the course of this investigation LPA made observations and documents were reviewed. Based on R1’s care plan and shower sheets for the months of August, September, and October: records indicate that R1 did not receive showers in accordance with their care plan. In August, R1 received 2 showers, 8/9/24 and 8/25/24. In September R1 received 2 showers, 9/18/24 and 9/28/24;
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 5
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
10/09/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20241009090125

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:
12:12 PM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
02:32 PM
ALLEGATION(S):
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9
Staff do not ensure residents are provided meals
Staff do not ensure medications are dispensed as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conclude the complaint investigation regarding the above allegations and to deliver findings. LPA met with the Administrator Diana Paz.

LPA conducted an inspection of the facility on 9/10/24, 9/15/24,10/10/24 and 11/26/24 and found an ample supply of perishable and non-perishable foods available as per required by Title 22. In addition, LPA inspected the Memory Care (MC) kitchen and interviewed staff who stated that snacks are available for residents.

Continued on 9099C...

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 5
Control Number 21-AS-20241009090125
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 9099A...

Snacks and beverages for residents in AL are available at the coffee bar at the front of the building. Meals are provided for residents three (3) times per day and snack times are served in Memory Care at approximately 10 AM, 3PM and in the evening. According to the Administrator, the kitchen is staffed from at least 7 AM to 6 PM and staff can request food from the kitchen during that time, or requests can be made to med techs who can access kitchen outside of dining room hours. LPA was unable to substantiate the allegation that Staff do not ensure residents are provided meals. Food was found to be readily available and served at regular times with snacks and extra food available as needed therefore the allegation that Staff do not ensure residents are provided meals 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.

The complaint alleges that Staff do not ensure medications are dispensed as prescribed. LPA Nakagawa conducted a random inspection of the Centrally Stored Medication Records from August 2024 to October 2024 and found no irregularities in the records at the time of inspection; indicating Staff are dispensing medications as prescribed. 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.
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 5
Control Number 21-AS-20241009090125
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.....

and from October 1-10 R1 received 1 shower on 10/09/24. Based on LPA’s record review the preponderance of evidence standard has been met, therefore the allegation Staff do not ensure residents receive bathing services was found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 is being cited on the attached LIC 9099D.”)
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 5
Control Number 21-AS-20241009090125
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
87464(f)(4)
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87464 (f)(4)Basic Services. Basic services shall at a minimum include:...Personal assistance and care...such as dressing, eating, bathing..
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Administration to provide plan to provide training on the importance of showers by 11/27/24 and proof of refresher training to staff about the importance of showers by 12/05/2024.
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.***Based on documents, this requirement not met as evidenced by: Shower Sheets indicate R1 was not showered as per Care Plan from 8/01/2024 through 10/10/2024.This poses an immediate risk to the health and personal rights of R1.
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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: 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: 5 of 5