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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700594
Report Date: 06/06/2024
Date Signed: 06/06/2024 04:03:24 PM


Document Has Been Signed on 06/06/2024 04:03 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:WOODLAKE, THEFACILITY NUMBER:
342700594
ADMINISTRATOR:JESSICA SOMMERFACILITY TYPE:
740
ADDRESS:1445 EXPO PARKWAYTELEPHONE:
(916) 604-3780
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY:144CENSUS: 86DATE:
06/06/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Sandra ChizekTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an Annual Continuation visit. LPA met with Business Office Manager (BOM) Sandra Chizek, and explained the purpose of the visit.

On 06/05/2024, LPA Villanueva conducted the initial annual visit, toured the facility, and started the inspection care tool. No deficiencies were observed during his visit. On 06/06/2024, LPA Valerio observed the physical plant to be clean, organized, free from debris, and fully furnished. No emergency exits were obstructed. All necessary signage was observed to be posted and available for staff/resident review.

LPA Valerio reviewed eight (8) resident files, which included both Memory Care and Assisted Living files. Resident files were observed to be up to date with required assessment and care plans.

LPA Valerio reviewed ten (10) staff files. Staff files were up to date with required training. The facility conduct an emergency drill on 05/21/2024 and 04/04/2024.

LPA Valerio requested the following be sent to the Regional Office:
Fax Number (916) 263 - 4744
    LIC 500 Personnel Report
    LIC 308 Designation of Responsibility
    LIC 610 Emergency Disaster Plan
    Copy of Liability Insurance
Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, no deficiencies were observed during the visit.

An exit interview was held with BOM Chizek, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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