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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700594
Report Date: 12/27/2021
Date Signed: 12/27/2021 02:39:03 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
11/15/2021 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20211115143619
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: 84DATE:
12/27/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Karen WoodTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff take too long to respond to call buttons.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 12/27/2021 at 1:25 pm to deliver the complaint findings. LPA Truong met with Sales Manager, Karen Wood who called Administrator Michelle Swearingen, who said it was alright for Karen to sign the LIC9099. LPA called and spoke with Michelle to deliver the complaint findings and discuss the Plan of Correction.

Throughout the course of the investigation, LPA Truong conducted interviews, reviewed facility documents, and toured the facility.

The complaint alleged that staff take too long to respond to call buttons. Based on interviews and review of pendant alarm records, LPA Truong found that from 11/25/2021 to 12/1/2021 there were (6) pendant pressed with response time of over 30 minutes and

Report continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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 5
Control Number 27-AS-20211115143619
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
VISIT DATE: 12/27/2021
NARRATIVE
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(4) with response time of over (1) hour. In addition, there were (8) bedside pull switch
with response time of over 45 minutes.

As a result of this investigation, the Department finds the 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. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

An exit interview was conducted, a copy of this report, LIC 9099-D, and appeal rights were provided.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
11/15/2021 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20211115143619

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: 84DATE:
12/27/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Karen WoodTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are not assisting residents with hygiene.
Resident rooms are dirty.
There is an odor.
Residents are not getting all of their meals.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 12/27/2021 at 1:25 pm to deliver the complaint findings. LPA Truong met with Sales Manager, Karen Wood who called Administrator Michelle Swearingen, who said it was alright for Karen to sign the LIC9099.

Throughout the course of the investigation, LPA Truong conducted interviews, reviewed facility documents, and toured the facility.

The complaint alleged that staff are not assisting residents with hygiene. Based on interviews and statements obtained during the investigation, residents stated that staff are assisting them with hygiene. Residents reported being satisfied with the care they received and have no complaints. Although the allegation may be valid, there is not a

Report continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20211115143619
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
VISIT DATE: 12/27/2021
NARRATIVE
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preponderance of evidence to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

The complaint alleged that resident rooms are dirty. Based on the interviews and statements obtained during the investigation, residents stated that housekeeping clean their room once a week. Residents reported that they have not seen any rooms that are dirty. LPA observed a sample of (15) rooms and found the rooms to be clean. Although the allegation may be valid, there is not a preponderance of evidence to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

The complaint alleged that there is an odor. Based on the interviews and statements obtained during the investigation, residents stated that they didn’t know of any rooms to have odor. Staff (S1) and (S2) stated that room 117 has odor due to resident’s having bm and is on hospice. LPA spoke with the family of resident in room 117 and learned that facility staff are doing everything they can for the resident. The family stated there were no concerns with the care being provided. LPA observed a sample of (15) rooms and did not found any other rooms to have odor. Although the allegation may be valid, there is not a preponderance of evidence to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

The complaint alleged that residents are not getting all of their meals. Based on the interviews and statements obtained during the investigation, residents stated that they are receiving all of their meals. Although the allegation may be valid, there is not a preponderance of evidence to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

As a result of this investigation, the Department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated 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.

An exit interview was conducted and copy of this report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20211115143619
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: 12/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Facility shall formulate a plan of action to ensure that all residents receive timely responses when a need is expressed. Proof of action plan to be sent to CCLD by POC date.
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Based on interviews and review of records, the Licensee did not ensure that residents receive timely respones when the call pendant is pressed, which posed an immediate 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: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5