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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700594
Report Date: 01/17/2025
Date Signed: 01/17/2025 12:15:20 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2024 and conducted by Evaluator Holly Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241021094841
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: 109DATE:
01/17/2025
UNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Martin NicholsTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator is not permitting resident's authorized representative to participate in decisions regarding resident's care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Holly Williams made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPA Williams met with facility administrator Martin Nichols and together discussed the investigation details.
This investigation consisted of interviews, observations, and record review. LPA Williams interviewed two staff members (S1-S2), Caregiver, and one resident (R1).
R1 was given pain medication on 10/16/24 and 10/17/24 according to what was found in the investigation the pain medication made R1 decompensate, and the pain medication was discontinued.
According to the Medication Administration Report (MAR) the medication was given on 10/16/24 and 10/17/24 and then ordered to stop and not to be given without consent.
During the investigation the medical power of attorney is found to be valid.
Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Nichols.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
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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