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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700594
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:57:27 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2021 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20210810092050
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
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Meghna DavidsonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff failed to administer residents' medication in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 09/09/2021 at 1:39 pm to deliver complaint findings, LPA met with Assistant Administrator, Meghna Davidson, and explained the purpose of the visit.

Throughout the course of the investigation, the Department conducted interviews, toured the facility, observed medication passes, and reviewed facility documents. LPA Martinez reviewed 5 residents' Medication Administration Records (MAR). It was learned the facility had a total of 41 late medication administration passes for the months of July and August 2021. The average late time was two (2) hours.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D report, per Title 22 Regulations.

An exit interview was conducted with Meghna Davidson. Copy of this 9099 report, LIC 9099-D report, and appeal rights were provided to Meghna Davidson.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20210810092050
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
09/15/2021
Section Cited
CCR
87465(a)(5)
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87465(a)(5)Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed.

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Meghna Davidson agrees to the following: Implementing a lock medication cart by POC 09/15/2021.
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This requirement was not met as evidence by: Based on record review the facility had a total of 41 late medication administration passes for the months of July and August. This posed a potential health and safety risk to residents 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2021 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20210810092050

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
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Meghna DavidsonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Insufficient staffing to meet the residents’ needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 09/09/2021 at 1:39 pm to deliver complaint findings, LPA met with Assistant Administrator, Meghna Davidson, and explained the purpose of the visit.

Throughout the course of the investigation, the Department conducted interviews, toured the facility, observed medication passes, and reviewed facility documents. LPA Martinez conducted 5 interviews with staff and conducted 5 interviews with residents. It was learned that there were no concerns with care that was being provided to residents. Staff indicated they were able to complete all their care staff duties. Residents reported being satisfied with the care they are receiving. It was also learned the facility has been utilizing staffing agencies to fill vacations and medical leave absences.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 3