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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700594
Report Date: 11/25/2024
Date Signed: 11/25/2024 12:05:48 PM

Substantiated


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
10/01/2024 and conducted by Evaluator Holly Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241001170841
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: 100DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sandra ChizekTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility is not administering medications as prescribed.
Facility staff are instructing residents to be mean to other residents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPAs Williams and Moleski spoke with facility administrator Martin Nichols over the phone and together discussed the investigation details. Nichols said business office manager Sandra Chizek could sign this report in his absence.

This investigation consisted of interviews, observations, and record review. LPA Williams interviewed Nichols. 11 staff members (S1-S11), 2 residents (R1-R2), and R1’s responsible party (R1’s RP).
According to an incident report dated 10/07/2024, R1 was not getting the correct dosage of medication from 9/5/24 through 9/19/24. According to the incident report, R1 was receiving 125 milligram doses of the medication but should have been receiving 500 milligram doses. According to the incident report, R1 was exhibiting aggressive behaviors during that time. In an interview, Nichols said the medication error occurred between 9/1/24-9/19/24. According to the incident report, on 9/5/24, R1’s higher dose medication was erroneously taken off hold by S10 with no orders to do so. R1 was instead receiving 125 milligram pills of the medication twice per day. [Continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20241001170841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/25/2024
NARRATIVE
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LPA Williams reviewed R1’s Medication Administration Record (MARS) for the month of September 2024. LPA Williams observed that R1 was not given any doses of the medication August 29th, 30th and 31st and September 1, 2, 3, 4 and the morning of the 5th. R1 was given 125mg doses from the evening of 9/5/24 to the morning of 9/19/24. The 500 mg doses were not given from 9/1/24- 9/19/24. LPA Williams interviewed R1’s responsible Party (R1’s RP). R1’s RP said that they were informed about the medication error by S10. R1’s RP said that according to S10, somewhere at the end of August early September, R1 had run out of medication. R1’s RP asked S10 if it had been reordered and S10 said,” I think so,” according to R1’s RP.
According to staff member interviews conducted on 10/29/2024, Staff 3 (S3) stated that the 125 mg doses went on hold and that they stopped giving R1 the medication. S4 did admit to an issue with Resident 1 (R1) and their medication, and that the medication was put on hold by another staff member and that the communication between staff members was faulty and could be improved.
In an interview, Nichols said that R1 thinks R2 is R1’s wife and R1 has been aggressive with R2. In an interview, R2 said that staff members of the facility had told them to be “mean” to R1, and to use a “mean, loud voice” when speaking with R1. In an interview, S4 said they told R2 to stick up for themselves, told R2 to say go away, scream for help, or tell R1 that they were scaring R2. In an interview, S6 said that other staff members told R2 to be stern with R1. In an interview, S6 said that R2 yells at R1. In an interview, S7 said that R1 would get in R2’s face and R2 would lash out at them and tell them off. S7 said they encouraged R2 to tell R1 to go away. In an interview, S7 said that R2 would blow up on R1. In an interview, S5 said that they had heard other staff members tell R2 to tell R1 “get the fuck out of my face.” In an interview, S5 said they told R2 that R2 should tell R1 “I don’t need you, I don’t want you, leave me alone,” and S5 told R2 to yell if R2 wants.

The department has determined the following regarding the allegations that the facility is not administering medications as prescribed, and that facility staff are instructing residents to be mean to other residents:
Based on interviews and record review, the above allegations are SUBSTANTIATED, which means that the allegations are valid because the preponderance of the evidence standard has been met.
This facility is hereby cited per 22 CCR Sections 87468.1(a)(1) and 87465(a)(4). An exit interview was conducted with Nichols. A copy of this report and appeal rights were left with Chizek.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/01/2024 and conducted by Evaluator Holly Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241001170841

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: DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sandra ChizekTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility is illegally evicting resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPAs Williams and Moleski spoke with facility administrator Martin Nichols over the phone and together discussed the investigation details. Nichols said that business office manager Sandra Chizek could sign this report in his absence.

This investigation consisted of interviews, observations, and record review. LPA Williams interviewed Nichols. 11 staff members (S1-S11), 2 residents (R1-R2), and R1’s responsible party (R1’s RP).
LPA Williams reviewed an eviction notice for R1, dated 8/22/24. The cause for eviction in this notice is failure to comply with general facility policies. The eviction states that on 6/18/2024, R1 held another resident against the wall by the throat. LPA Williams reviewed an incident report sent into the Community Care Licensing Division (CCLD) that states that on 6/18/24 a client was choked by R1 and R1’s RP took R1 out of the facility. LPA Williams reviewed progress notes for R1 dated 7/23/24, which state that there was an increase in medication. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241001170841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/25/2024
NARRATIVE
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According to R1’s eviction notice, on 7/23/24, R1 became aggressive toward multiple staff resulting in one staff member suffering a black eye. LPA Williams reviewed an incident report sent to CCLD which states that the resident became aggressive towards staff members and was unable to be redirected on that same date. R1 was sent out to the hospital, a psychiatrist evaluated R1, and R1’s medication were adjusted, according to the incident report.
According to the eviction notice, on 8/14/24 R1 hit the back of another resident’s wheelchair with an open hand 2-3 times near their upper back on the soft vinyl area on their wheelchair. The resident jolted forward as their wheelchair was struck. The resident was shaken but uninjured, according to the eviction notice. LPA Williams reviewed an incident report which confirmed the incident as described in the eviction notice.
LPA Williams reviewed R1’s admission documents, and observed a document titled Reservation Confirmation, which was signed by R1’s responsible party on 6/11/24. The document stated that by signing, R1’s responsible parties agreed to the facility’s move in/move out criteria. Number six of the move in/move out criteria states that a resident may be evicted if they “exhibit… behaviors that affect the safety or wellbeing of the resident, other residents, and/or cannot be successfully re-directed through staff assessments and interventions.” LPA Williams observed in R1’s progress notes that there were several attempts as stated above to intervene, such as the Access Care Nurse assessments, several medication changes, hospitalizations, and redirections. LPA Williams reviewed R1’s MARs dated between 6/18/24 and 8/22/24 and observed no medication errors present.
The department has determined the following as it relates to the allegation is that the facility is illegally evicting a resident:

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.

Although this allegation is unsubstantiated, LPA Williams reviewed R1’s financial records, which showed that this facility accepted payment beyond service of the eviction notice, thus extending R1’s contract past the effective date of the eviction. Therefore, while the notice is lawful, this facility must re-serve the notice without continuing to collect payment if staff wish to terminate R1’s contract.

No deficiencies were cited regarding the above allegation. An exit interview was held, and a copy of this report was left with Business Office Manager Sandra Chizek.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20241001170841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met as evidenced by:
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Licensee agrees to provide a statement of plan of correction by POC due date. Holly.williams@dss.ca.gov
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Based on interviews and record review staff members did not accord a resident dignity in their relationships with another resident, which poses an immediate health and safety risk.
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Type A
11/26/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Licensee agreed to send a statement of their plant to correct the med error with staff.Holly.Williams@dss.ca.gov
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Based on interviews and record review the facility did not administer medications as needed 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5