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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700594
Report Date: 09/16/2020
Date Signed: 09/16/2020 03:54:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:WOODLAKE, THEFACILITY NUMBER:
342700594
ADMINISTRATOR:SWEARINGEN,MICHELLEFACILITY TYPE:
740
ADDRESS:1445 EXPO PARKWAYTELEPHONE:
(916) 604-3780
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY:144CENSUS: 17DATE:
09/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michelle Swearingen; AdministratorTIME COMPLETED:
04:00 PM
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On 9/16/2020 at 3PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced virtual Case Management visit regarding an AWOL incident report that was received on 9/14/2020. A virtual visit was made in compliance with the department's procedure regarding COVID-19. LPA spoke to Administrator Michelle Swearingen and explained reason for visit.

Prior to visit, LPA had requested for and reviewed R1's incident report on 9/13/2020 and R1's physician's report. After careful review and discussion with the Administrator, LPA concluded the following. Although the R1 left the facility's Memory Care Unit (MCU) and R1's physician's report indicate that R1 is unable to leave unassisted, the facility had security measures in place and took appropriate actions. Facility has a delayed egress system with a triggering alarm. Also, all MCU staff are equipped with an IPod that is virtually connected to the facility's MCU delayed egress alarm system. MCU had five residents and two working staff members. When R1 left the facility, S1 and S2 was notified via their IPod and they did a quick scan of the MCU to verify the census. S1 cleared the MCU's alarm system within four minutes and notified front desk staff, S3 and S4, regarding the alarm. S3 and S4 searched the perimeter and observed R1 was across the street. The MCU exit door opens into the facility parking lot which leads to public roads.

Facility has sufficient staffing, security system in place, and responded in a timely manner.

No deficiency observed.

Exit interview conducted. Two copies of report was given and LPA requested for facility to return a signed copy.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916)709-6317
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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