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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002856
Report Date: 01/16/2024
Date Signed: 01/16/2024 10:33:26 AM

Document Has Been Signed on 01/16/2024 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WOODSIDE RESIDENTIALFACILITY NUMBER:
345002856
ADMINISTRATOR:OSAH, EDIRINFACILITY TYPE:
735
ADDRESS:6921 WOODSIDE DRTELEPHONE:
(916) 676-2631
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 5DATE:
01/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Edirin OsahTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 01/16/24 to conduct a case management visit regarding an incident report Community Care Licensing (CCL) received on 01/08/24, LPA met with Edirin Osah , Administrator, S1, and explained the purpose of the visit.


Incident report received on 01/08/24 stated that resident, R1 was found unresponsive on the morning of 01/08/24 by staff during morning care. Staff called 9-1-1 and R1 was transferred to hospital to seek medical care. S1 stated that they got a call from hospital on 01/16/24 that R1 was discharged from hospital and been placed at short tern skilled nursing facility for rehab treatment. S1 stated that R1 will come back to facility after the short term rehab treatment if R1 qualify to get admit back to facility per R1s health condition.

After record review and interview with staff, it has been concluded that the facility took appropriate measures to address R1s health condition on 01/08/24 and send them to hospital to seek medical care in timely way.

There are no deficiencies being cited as a result of todays visit.

Exit interview conducted and copy of report left at the facility.





SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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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