340313203-11-4-2020-27-AS-APEZ-BV3P79-20201105100332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340313203
Report Date: 11/04/2020
Date Signed: 11/04/2020 03:56:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2020 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201008140235

FACILITY NAME:	WOODLAKE GUEST HOME		FACILITY NUMBER:	340313203
ADMINISTRATOR:	MANGABAT, NORMINIO & GLADY		FACILITY TYPE:	740
ADDRESS:	1002 LOCHBRAE ROAD		TELEPHONE:	(916) 649-1082
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95815
CAPACITY:	14	CENSUS: 12	DATE:	11/04/2020
		UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Norminio Mangabat, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Lack of staff supervision resulted in a staff being hit by a resident in home.

INVESTIGATION FINDINGS:

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On November 4, 2020 at 11:11 am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons called the facility due to Covid 19, to findings for complaint # 27-AS-20201008140235. LPA met with Licensee Mangabat and informed him the reason for the visit.

During the course of the investigation, LPA reviewed facility records and conducted interviews. The complainant alleged there was a ‘lack of staff supervision which resulted in a staff member being hit by a resident in the home.’ LPA observed neither the resident nor the staff/family member was present in the home. According to the licensee in an interview on October 14, 2020, his family member (FM), 81-year-old aunt, stayed at the facility a few days to visit, while on vacation. The Licensee stated his FM was never a staff member nor lived at the facility. Personnel records confirm the statement. The Licensee’s family member enjoyed helping with chores around the house. On September 29, 2020 LIC was taking groceries in the house and FM was helping. Resident #1 (R1), was blocking the entry into the kitchen.

To continue see 9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

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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Control Number 27-AS-20201008140235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WOODLAKE GUEST HOME	FACILITY NUMBER: 340313203
	VISIT DATE: 11/04/2020

NARRATIVE

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FM asked R1 to step aside so she could get through. On her way down the stairs, R1 bumped FM causing her to lose balance and fell to the ground. The licensee states, “It was not intentional, it was an accident.” FM was taken to the hospital for evaluation. FM is now doing well, but suffered a laceration to the head as a result. FM is currently in Stockton CA, visiting more family members and is not returning to the facility. R1 was taken to Psychiatric Ward for evaluation. When R1 was discharged from the hospital, the social worker removed R1 from the facility and will not be returning.

Based on records reviewed and interviews conducted, the allegation that ‘Lack of Staff Supervision Resulted In a Staff Being Hit By a Resident in the Home’ is UNFOUNDED meaning that the allegation is false, could not have happened, and /or is without a reasonable basis.

Per California Code of Regulation, Title 22, no citations were issued.

An exit interview was conducted and a copy of this report was sent to licensee for signature and return a signed copy to CCLD

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC9099 (FAS) - (06/04)

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