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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700594
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:59:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WOODLAKE, THEFACILITY NUMBER:
342700594
ADMINISTRATOR:SWEARINGEN,MICHELLEFACILITY TYPE:
740
ADDRESS:1445 EXPO PARKWAYTELEPHONE:
(916) 604-3780
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY:144CENSUS: 73DATE:
09/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Meghna DavidsonTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 09/09/2021 at 1:39 pm to conduct a case management visit, LPA met with Assistant Administrator, Meghna Davidson, and explained the purpose of the visit.

The purpose of the case management visit is to follow up on a deficiency found during a complaint investigation reference # 27-AS-20210810092050. It was learned during medication passes, medicines are stored in an unlocked rolling cart. The rolling cart is taken into residents' apartments during medication passes. As a result, centrally stored medicines are not kept in a safe and locked place or locked medication cart.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.


An exit interview was conducted, and a 809 and 809D report was given to Meghna Davidson. In addition, Meghna Davidson was given a copy of the appeals right document.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WOODLAKE, THE
FACILITY NUMBER: 342700594
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited

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Incidental Medical and Dental Care 87465(h)(2):The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement was not met as evidence by: Based on observation and interviews residents' medicines were not stored in a secured/lock place or locked medication cart. This posed an potential health and safety risk to resident in care.
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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) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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