342700594-8-5-2024-27-AS-HWIS-D7URSN-20240805131701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700594
Report Date: 08/05/2024
Date Signed: 08/05/2024 01:17:07 PM

Document Has Been Signed on 08/05/2024 01:17 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, 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: 94	DATE:	08/05/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Corrina Goode		TIME COMPLETED:	01:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Holly Williams met with the health and wellness director Corrina Goode and explained the purpose of the visit. LPA Williams reviewed resident records for four residents (R1-R4). LPA Williams reviewed an incident report that stated that an incident took place on 7/23/2024 involving R1 and staff. R1 was aggressive with a medication technician and hit the staff member, according to Goode. Afterward, R1 was aggressive with Goode. R1 was unable to be redirected and 911 was called, according to the incident report. R1 had medications adjusted while at the hospital, and R1 came back to the facility with a behavior therapist to help manage behaviors. R1's LIC 602 was dated 6/13/2024 and stated that the resident had no aggressive tendencies. R1 does have a diagnosis of dementia, according to R1's LIC 602. R1's assessment, dated 6/12/2024, indicated that R1 had no signs of aggressive behavior. LPA Williams reviewed an incident report for R2 and R3. The incident report stated that R2 hit R3 in the abdomen. Staff were able to redirect but R2 was continuing to be aggressive, according to Goode. Goode said that R2 woke up agitated. Goode said R2 then went into the dining room but it was locked and was aggressive with staff and R3. Goode stated that R3 was merely walking by, and R2 targeted R3 for an unknown reason. R2 was taken to the hospital and R2's medications were adjusted, according to the incident report. R2's assessment documentation stated that R2 had not been previously aggressive with staff or residents. [continued on 809-C]

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly Williams	TELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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: 08/05/2024

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LPA Williams reviewed an incident report for R4 and it stated R4 became aggressive with care staff while assisting with changing R4's clothes on 7/31/2024. R4 kicked staff and R4 was taken to the hospital, according to the incident report. R4 did not have medications adjusted because R4 was not aggressive with hospital staff, according to Goode. R4 has dementia, according to R4's LIC 602, dated 5/15/2024. R4's intake assessment, dated 4/6/22, stated there was a past history of aggression, however, R4's most recent LIC 602 indicated that R4 was not aggressive. Goode said that she was not aware of any aggressive behavior from R4 while at the facility.

Goode said that staff were provided an inservice training on behavioral management and provided a sign in sheet dated 7/31/24. Goode said that further training on redirection is scheduled in October.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Goode.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly Williams	TELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

LIC809 (FAS) - (06/04)

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