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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700594
Report Date: 03/04/2022
Date Signed: 03/04/2022 03:59:04 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
12/02/2021 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211202130622
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: 95DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Michelle SwearingenTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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-Residents are sustaining injuries due to an unwitnessed falls
-Residents are sustaining unexplained injuries while in care
-Resident's are being left unattended for an extended period of time
-Staff did not safeguard residents personal property
INVESTIGATION FINDINGS:
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On 3/4/22 at 1:15 pm, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. A risk assessment call was performed prior to entry verifying there were no active covid cases. LPA Hopkins met with Administrator Michelle Swearingen and explained the purpose of today's visit.

Regarding the allegation of Residents are sustaining injuries due to an unwitnessed falls, the Department found the following: based on interviews on record review it was determined Resident 1(R1) was brought to his/her room after dinner due to him/her telling the caregiver he/she wanted to go to bed. The caregiver helped with washing R1's face and brushing R1's teeth and getting him/her ready for bed. R1 was helped get to bed and the caregiver left R1's wheelchair near the bed. According to multiple staff and the incident report, R1 tried getting out of bed him/herself and going to use the bathroom (by wheelchair) without notifying staff, this is when she fell and hit the side of his/her head.
Report continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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-20211202130622
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: 03/04/2022
NARRATIVE
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Staff 1(S1) came back to check on R1, noticing R1 on the bathroom floor. After this incident R1's responsible party and Physician stated R1 needed 24/7 supervision.

Regarding the allegation of Residents are sustaining unexplained injuries while in care, the Department found the following: based on interviews and record review, it was determined that Resident 2(R2), Resident 3(R3), and Resident 4(R4) injuries were due to falls. Resident 2(R2), Resident 3(R3), and Resident 4(R4) are all memory care residents. R2, R3, and R4 use assistive walking devices (ie cane or walker). There were incident reports for each of there falls explaining what happened.

Regarding the allegation of Residents are being left unattended for an extended period of time, the Department found the following: based on interviews it was determined that R1's responsible party observed memory care residents eating alone when eating their meals. R1's responsible party felt memory care residents should have staff sitting with them while eating. Administrator stated that all residents in memory care are able to feed themselves and eat on their own.

Regarding the allegation of Staff did not safeguard residents personal property, the Department found the following: based on interview, it was determined that Administrator offered to safeguard R1's hearing aid, keeping it in the medication cart, but R1's responsible party refused to do that.

LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator Michelle Swearingen. A copy of this report was left with Administrator upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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
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
12/02/2021 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211202130622

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: 95DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Michelle SwearingenTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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-Insufficient staffing to meet the residents’ needs
INVESTIGATION FINDINGS:
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On 3/4/22 at 1:15 pm, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. A risk assessment call was performed prior to entry verifying there were no active covid cases. LPA Hopkins met with Administrator Michelle Swearingen and explained the purpose of today's visit.

Regarding the allegation of Insufficient staffing to meet the residents’ needs, the Department found the following: based on interview, observation, and record review, it was determined that at least three residents did not eat breakfast on time, eating breakfast 2 hours late, did not get their clothes changed on time (going to breakfast in their pajamas), and did not get their medications on time due to one staff being present from 630am-930am on most Sundays. Based on R1's care plan after sustaining his/her latest fall, R1's care plan states there needs to be a 2 person assist with transfers. LPA observed 1 person assisting with transfers.
Report continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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-20211202130622
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: 03/04/2022
NARRATIVE
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R1's companion also stated that numerous times when she would pull the emergency cord for staff assistance, it would take them 30 mins to over an hour to come to the room.

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: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20211202130622
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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [...]
This requirement was not met as evidenced by:
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Administrator has already gotten a staffing agency to use when there are multiple call-offs. Administrator has agreed to have a plan in place when there are multiple call-offs, and will send that plan to LPA via email by POC due date 3/11/22
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Based on interviews, observation, and record review the Licensee did not ensure sufficient staffing was in place in the memory care unit, having 1 staff working from 630am- 930am due to other staff calling in sick. This poses 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: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5