<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701551
Report Date: 07/01/2026
Date Signed: 07/01/2026 02:57:08 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
03/16/2026 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260316101557
FACILITY NAME:WOODLAKE, THEFACILITY NUMBER:
342701551
ADMINISTRATOR:ROSS, LATRICEFACILITY TYPE:
740
ADDRESS:1445 EXPO PARKWAYTELEPHONE:
(916) 472-5773
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY:144CENSUS: 93DATE:
07/01/2026
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Latrice RossTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent another resident from injuring a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct a complaint investigation into the allegations mentioned above. LPA met with the Administrator and explained the purpose of the visit.

On 03/14/2026, Community Care Licensing (CCL) received a cross report from Adult Protective Services (APS) regarding SOC 341 Report ID 267329. The report stated that R1 was transported by ambulance to UC Davis Medical Center after another resident pushed her, causing her to fall and strike her head on the floor. It was reported that R1 experienced pain to her forehead, nose bridge, and abdomen. Law enforcement and R1’s spouse was notified.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
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-20260316101557
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: 342701551
VISIT DATE: 07/01/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the investigation, LPA obtained and reviewed the facility’s Administrator Report dated 03/13/2026, which documented that staff witnessed R2 push R1 in the hallway, causing R1 to fall to the floor. Staff noted mild redness to the back of R1’s head and assisted her from the floor. Vital signs were stable.

R1 was transported to UC Davis Medical Center for evaluation. Hospital documentation indicated R1 was assessed for possible neck injury; MRI/scan results did not identify acute injury, and R1 returned to the facility with no new treatment recommendations.
Although staff responded after the fall, the facility did not demonstrate that adequate supervision or preventive measures were in place to protect R1 from resident-to-resident aggression.

The Administrator Report confirms staff witnessed the push as it occurred, indicating the altercation was not prevented. The facility did not provide documentation showing proactive monitoring, behavioral interventions, or supervision sufficient to prevent the incident before physical contact occurred.

Based on the SOC 341 report, Administrator Report, hospital documentation, and interviews, the facility failed to protect R1 from a foreseeable health and safety hazard. Therefore, the allegation that staff did not prevent another resident from injuring R1 is substantiated.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260316101557
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: 342701551
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2026
Section Cited
CCR
87468.1(a)(1)
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
1
2
3
4
5
6
7
The Facility has conducted an in service to address the behavior challeges of R2 and has established a plan to provide R2 with additional support.
8
9
10
11
12
13
14
This requirement was not met as evidenced by records and interviews that R2 pushed R1 to the floor, causing R1 to go to the ER for evaluation. A potential health and safety risk to residents in care
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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3