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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 576804194
Report Date: 04/15/2025
Date Signed: 04/15/2025 10:57:32 AM

Unsubstantiated


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
01/22/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250122110522
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: 67DATE:
04/15/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff engaged in inappropriate abusive behavior with resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Diana Paz, Administrator. During the investigation LPA reviewed records, made observations at the facility, and conducted interviews.

It is alleged that Staff (S1) has engaged in inappropriate behaviors by throwing a towel at Resident (R1) and intentionally moving R1’s walker out of reach.

Continued on 9099.......
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
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 2
Control Number 21-AS-20250122110522
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: 04/15/2025
NARRATIVE
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Continued from 9099....

LPA Nakagawa reviewed medical records of R1 and found that R1 had been refusing medications, exhibiting uncharacteristic behaviors and requiring medical interventions. A review of S1’s personnel file and interview of Administrator revealed that S1 has never been written up or reprimanded in the 7 years employed at the facility, is kind to the residents and of good moral character. This incident was during the same time frame of R1 receiving the medical intervention. Due to the medical information received and statement by R1(after receiving medical treatment) stating that there was no physical abuse-only a towel being handed to R1 curtly by S1; S1’s employment record; and Administrator’s assessment of S1’s character, the allegation that Staff engaged in inappropriate behavior 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2