342700594-4-18-2023-27-AS-AMAZ-CQZSPR-20230418140335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700594
Report Date: 04/18/2023
Date Signed: 04/18/2023 02:03:40 PM

Document Has Been Signed on 04/18/2023 02:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	WOODLAKE, THE		FACILITY NUMBER:	342700594
ADMINISTRATOR:	JESSICA SOMMER		FACILITY TYPE:	740
ADDRESS:	1445 EXPO PARKWAY		TELEPHONE:	(916) 604-3780
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95815
CAPACITY:	144	CENSUS: 86	DATE:	04/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Sandran Chizken, Kyle Larson, Melissa Cannone		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 04/18/2023 at 8:15 AM. LPA Martinez met with Sandran Chizken, Kyle, and Melissa Cannone and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds a current certificate. The facility is licensed for 144 non-ambulatory residents, which 58 residents may be bedridden. The facility has a hospice waiver for 25. There are currently 86 residents who reside at this facility.

LPA Martinez toured the facility with Kyle Larson on 04/18/2023 at 1:00 PM.

During today's visit, the facility common areas were furnished and clean. In addition, the facility has hand sanitizer throughout the facility. Moreover, LPA Martinez inspected four residents' bathroom sink water temperature, which were 109, 111, 110, and 111 degrees. LPA Martinez also, inspected one resident common bathroom sink temperature, which measured at 106 degrees. The facility temperature measured at 78 degrees. The facility kitchen was clean and sanitary, and had an adequate food supply. The fire extinguishers are in good repair, and the last fire inspection was this month April of 2023. Last fire drill was in March of 2023. The exterior resident patio areas were furnished and sanitary. LPA Martinez reviewed ten resident files, and all files were complete and up to date. LPA Martinez reviewed two residents' medication administration record, and both files were up to date. LPA Martinez reviewed ten staff files. four out of ten staff files did not have first aid certificates. During today's annual inspection, facility staff scheduled first aid training for all staff on April 26, 2023.

As a result of this visit, the following deficiency was cited, per California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of the 809, 809-D, and appeals right were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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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Document Has Been Signed on 04/18/2023 02:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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, THE	FACILITY NUMBER: 342700594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

17411 Personnel Requirements – General (c) (1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69…Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and file review 4 out of 10 staff files did not have first aid certificates. This posed a potential health and safety risk to residents in care.
	POC Due Date: 05/02/2023
	Plan of Correction
1 2 3 4	Facility staff has scheduled an Alpha 1 first aid training on 04/26/2023. Facility staff agrees to email all training document to LPA Martinez by POC date 05/02/2023 by 5 PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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