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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700594
Report Date: 07/15/2024
Date Signed: 07/15/2024 03:09:59 PM


Document Has Been Signed on 07/15/2024 03:09 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: 94DATE:
07/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Corrina GoodeTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced in order to conduct a case management visit to follow up on incident reports received from this facility. LPAs Moleski and Williams met with health and wellness director Corrina Goode and explained the purpose of the visit.

LPAs Moleski and Williams reviewed an incident report dated 7/11/24. The incident report stated that a resident (R1) was found lying in bed with an empty bottle of liquid medication nearby on 7/9/24. R1's hospice nurse was called and 911 was called. R1 was taken to the hospital. LPAs Moleski and Williams reviewed R1's file. R1 was admitted to this facility in early July. R1's LIC 602, dated 7/1/24, indicated that R1 was able to store and administer medications. R1 was not diagnosed with any kind of cognitive decline or mental health issues. R1 had no history of confusion, depression, or self-abuse. R1's pre-admission assessment indicated that R1 could store medications, could determine when medications need to be taken, and could determine the correct dose of medications. Interviews with three staff members present during the incident (Goode, S1 and S2) corroborated the narrative provided in the incident report. None of the three staff members interviewed were aware of any issues R1 might have had with medications, or any time that R1 had experienced depression.

LPAs Moleski and Williams reviewed a second incident report, dated 7/12/24. The incident report states that a resident (R2) had walked out a side door in memory care on 7/6/24. R2 walked out the door, around the side of the facility, and in through the front door. LPAs Moleski and Williams reviewed video camera footage which corroborated the narrative in the incident report. LPAs Moleski and Williams reviewed R2's file. R2's LIC 602, dated 4/30/24, indicates that R2 is not permitted to leave the facility unassisted. A second LIC 602, dated 6/11/24, indicates that R2 needs supervision when leaving the facility due to mobility impairment. R2's service agreement, dated 6/10/24, states that "care staff will assist [R2] with ambulation for safety due to fall risk." The service agreement also states that R2 has "high fall risk." The appraisal also states that R2 is at a "high risk for falls." [continued on 809-C]
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WOODLAKE, THE
FACILITY NUMBER: 342700594
VISIT DATE: 07/15/2024
NARRATIVE
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LPAs Moleski and Williams interviewed a staff member who was present during R2's elopement (S3). S3 said that they had heard the alarm going off, but saw another staff member providing assistance to another exit-seeking resident. S3 said that they assumed the other staff member would have seen anyone who had managed to go outside through the side door, so S3 locked the door. S3 was not aware that R2 had left until about 10 minutes later, when R2 was brought back to the memory care unit by assisted living staff.

This facility is being cited per HSC Section 1569.312(a). An exit interview was held with Goode. Appeal rights and a copy of this report were left with Goode.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 07/15/2024 03:09 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WOODLAKE, THE
FACILITY NUMBER: 342700594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2024
Section Cited
HSC
1569.312(a)

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"Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2." This requirement was met as evidenced by:
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Licensee has already conducted a staff training regarding elopements and door alarms. Licensee agrees to send LPA Moleski a copy of the sign-in sheet.
vincent.moleski@dss.ca.gov
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Based on interviews and record review, R2 left the memory care unit and was unsupervised in the parking lot and other outdoor areas, despite needing assistance with ambulation and fall prevention, which poses an immediate health and safety risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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