342700594-1-17-2025-27-AS-KHOS-DD6JDC-20250122055719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700594
Report Date: 01/17/2025
Date Signed: 01/17/2025 04:02:35 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
09/09/2024 and conducted by Evaluator Holly Williams

COMPLAINT CONTROL NUMBER: 27-AS-20240909113241

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:	DATE:	01/17/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Martin Nichols		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not ensure that resident's needs are being met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (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 Nichols, seven staff members (S1-S10) and 2 residents (R1-R2).
In an interview, S8 said that S1 went into the break room and told everyone that the showers cannot be missed. In an interview S8 said showers are not being conducted on the scheduled days, staff members are putting the showers off on other staff members, and the showers never get done. In an interview, S8 said residents are complaining. In an interview, S8 said that S10 skipped resident R1 shower on 9/10/24,
[Continued on 809-C]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly Williams	TELEPHONE: 916-798-3161
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)

Page: 1 of 3

Control Number 27-AS-20240909113241

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: 01/17/2025

NARRATIVE

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R1 does not feel comfortable with S10 because S10 took R1 to go to the bathroom (R1 has escort services) after the resident was done R1 waited for 45 minutes, and was yelling help, help!! In an interview, S8 said this is when S8 found the resident R1 in the bathroom.

In an interview, S7 said on 10/22/24 when The Woodlake had staffing problems the showers suffered. In an interview, S7 said the showers are given late. S7 said that S1 told her the showers are not being given.
In an interview, R1 said staff members have left R1 in the bathroom a few times and R1 has been yelling help, help. In an interview, R1 said they were left for 20 to 25 minutes at a time, and this has happened 5-6 times. In an interview, R1 states the door is a fire door and is too heavy to open. In an interview, R1 said when R1 first came to the facility it took 3 weeks to get a shower.

In an interview, S9 said there was a time where they were short staffed in the end of August to the first half of September 2024, they were short staffed, and there were a couple employee's that were talked to about the showers being late or postponed.

In an interview, S1 admitted that there have been some issues on the PM shift with certain staff members not taking out the trash or not doing the laundry.

Based on interviews 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 87464(f)(4). An exit interview was conducted with Nichols. A copy of this report and appeal rights were left with Nichols.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly Williams	TELEPHONE: 916-798-3161
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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20240909113241

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: 01/17/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/31/2025 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	(f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing...	1 2 3 4 5 6 7	Licensee agrees to send the shower sign up sheet for November, December, and January. Licensee will write up a plan of correction with supervisor checks by POC due date. Holly.Williams@dss.ca.gov
	8 9 10 11 12 13 14	Based on observation, record review, and interview was not meeting residents basic needs which poses an potential health, safety and/or personnel rights risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly Williams	TELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC9099 (FAS) - (06/04)

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