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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 451373915
Report Date: 06/14/2024
Date Signed: 06/14/2024 01:40:38 PM


Document Has Been Signed on 06/14/2024 01:40 PM - 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:WOODCLIFF CARE HOMEFACILITY NUMBER:
451373915
ADMINISTRATOR:CALLOWAY, JAIMEFACILITY TYPE:
740
ADDRESS:165 WOODCLIFF DRIVETELEPHONE:
(530) 244-2467
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 6DATE:
06/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jaime Calloway- administratorTIME COMPLETED:
01:30 PM
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06/14/2024 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Jaime Calloway. Today’s visit is regarding a death report tht was submitted to licensing on 06/10/2024 by the facility concerning a death that occurred at the facility on 05/12/2024 and was reported to licensing on 5/13/2024. Resident 1 (R1) was not on hospice. Per the coroner’s report the immediate cause of death was ACUTE HYPOXIC RESPIRATORY FAILURE, the secondary cause of death was ASPIRATlON PNEUMONIA and DYSPHAGIA.

It was reported that on 5/11/2024 R1 was having difficulty breathing, staff called 911 and R1 was transported to the local emergency room for treatment. R1 was evaluated by hospital staff, placed on comfort care, and passed away on 5/12/2024.

During the course of the investigation, it was learned that R1 was generally declining in health status over time. R1 had a swallow test performed at the hospital and at a skilled nursing facility and both times it was determined that R1 did not require a modified diet. The facility had been feeding R1 a soft diet since he was discharged from the hospital 2 weeks prior to his death. R1’s family wanted R1 to come back to the facility after discharge from the hospital rather than go to skilled nursing. Even though the administrator had doubts as to whether R1 should come back to the facility based on R1’s declining health status, he allowed R1 to come back. It was determined that R1 was beyond acceptance and retention limitations of the facility based on his health status upon discharge from hospital, and recent admissions to skilled nursing.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Jaime Calloway.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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Document Has Been Signed on 06/14/2024 01:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WOODCLIFF CARE HOME
FACILITY NUMBER: 451373915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87455(c)(2)

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87455(c)(2) Acceptance and Retention Limitations (c) No resident shall be accepted or retained if any of the following apply: (2) The resident requires 24-hour, skilled nursing or intermediate care as specified in Health and Safety Code Sections 1569.72(a) and (a)(1). This requirement was not met as evidenced by:
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Administrator agrees to submit a plan to LPA outlining the steps he will take to determine whether a resident is suitable to be accepted back into the facility after discharge from hospital and/or skilled nursing.
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Based on interviews and document review it was determined that the licensee should not have accepted the resident back in the facility due to health decline after a series of hospital and skilled nursing stays which poses a potential health and safety risk to residents in care.
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Administrator to submit plan to LPA by 06/28/2024.

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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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