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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700594
Report Date: 10/15/2024
Date Signed: 11/08/2024 08:51:54 AM

Document Has Been Signed on 11/08/2024 08:51 AM - 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/
DIRECTOR:		JESSICA SOMMERFACILITY TYPE:
740
ADDRESS:1445 EXPO PARKWAYTELEPHONE:
(916) 604-3780
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 144TOTAL ENROLLED CHILDREN: 0CENSUS: 103DATE:
10/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Corrina GoodeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts LPAs Vincent Moleski and Holly Williams visited The Woodlake facility unannounced for a case management visit. LPAs Moleski and Williams met with Corrina Goode and explained the purpose of the visit.

On 10/7/24, an incident report was faxed to the Community Care Licensing Division (CCLD) regarding a medication error that occurred between the dates of 9/5/24-/9/19/24. During this time period, a resident (R1) was receiving an incorrect dose of a medication, according to the incident report. The author of the incident report said the written report was sent in to CCLD late.

CCLD received a second incident report on 10/7/24. According to the incident report, a resident (R2) reported money missing from their room on 8/5/24 and 9/19/24. The author of the incident report said that the written report was sent in to CCLD late due to clerical error.

LPAs Moleski and Williams will be following up on the incidents described in these reports at a later date.

This facility is being cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Corrina Goode. Appeal rights and a copy of this report were emailed to Corrina Goode.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161
DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/08/2024 08:51 AM - 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: 10/15/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
"...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
(D) Any incident which threatens the welfare, safety or health of any resident..." This requirement was not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 10/29/2024
Plan of Correction
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Licenssee agrees to conduct staff training and send sign in sheet to LPA Williams. Holly.williams@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024

LIC809 (FAS) - (06/04)
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