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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340313203
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:15:27 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, 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
05/04/2023 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20230504145055
FACILITY NAME:WOODLAKE GUEST HOMEFACILITY NUMBER:
340313203
ADMINISTRATOR:MANGABAT, NORMINIO & GLADYFACILITY TYPE:
740
ADDRESS:1002 LOCHBRAE ROADTELEPHONE:
(916) 649-1082
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY:14CENSUS: 11DATE:
05/05/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Norminio MangabatTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 05/05/2023 at 2:00PM to open a complaint investigation and close the complaint, LPA met with Norminio Mangabat and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted a tour with Norminio Mangabat and inspected the facility thermostats. LPA Martinez was informed the facility has a pest infestation. In addition, Norminio provided LPA Martinez pest control documentation. The pest company visits the facility every other month. The pest company's next scheduled visit is next month. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
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
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
05/04/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230504145055

FACILITY NAME:WOODLAKE GUEST HOMEFACILITY NUMBER:
340313203
ADMINISTRATOR:MANGABAT, NORMINIO & GLADYFACILITY TYPE:
740
ADDRESS:1002 LOCHBRAE ROADTELEPHONE:
(916) 649-1082
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY:14CENSUS: 11DATE:
05/05/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Norminio MangabatTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Licensee does not maintain facility at a temperature comfortable for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 05/05/2023 at 2:00PM to open a complaint investigation and close the complaint, LPA met with Norminio Mangabat and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted a tour with Norminio Mangabat and inspected the facility thermostats. LPA Martinez observed both thermostats in the facility. The facility thermostats were measured at 68 degrees. The facility windows are also kept open to air out the facility, however, it was reported the windows are closed at night and heating and air are left on. Norminio reported extra blankets are given to resident if they become cold. Resident 1 (R1) reported they received an additional blanket due to being cold. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20230504145055
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation:The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirment was not met as evidence by:
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The facility Licensee has already contracted a pest company, and is overseeing the pest infestation. The Licensee agrees to update LPA Martinez on the pest infestation until 06/30/2023. Updates will be done by email.
avelina.martinez@dss.ca.gov
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Based on interview review and file review, the Licensee did not ensure that facility did not have pest infestation. This posed a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3