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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700610
Report Date: 04/12/2024
Date Signed: 04/12/2024 10:54:04 AM

Document Has Been Signed on 04/12/2024 10:54 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WOODLAND COMMUNITY OPTIONSFACILITY NUMBER:
572700610
ADMINISTRATOR/
DIRECTOR:		PEFLEY, SHELLYFACILITY TYPE:
775
ADDRESS:45 W COURT STREETTELEPHONE:
(916) 283-8302
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 50CENSUS: DATE:
04/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Carlette Phipps, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced for the purpose of following up on a self-reported incident that was submitted to the Department and issue a citation. LPA toured the facility which was found clean and a comfortable temperature. The majority of the clients were observed engaging in activities with facility staff. It was reported that on 4/9/24 that client C1 did not receive a regularly prescribed feeding as required due to staff oversight.

LPA consulted with Program Manager Carlette Phipps regarding incident report and regulation 82092.10 Gastronomy Feeding, Hydration and Care.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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 04/12/2024 10:54 AM - It Cannot Be Edited


Created By: Jill Nakagawa On 04/12/2024 at 10:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WOODLAND COMMUNITY OPTIONS
FACILITY NUMBER: 572700610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
82092.10(a)(4)

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82092.10 Gastrostomy Feeding, Hydration, and Care(a) A licensee may accept...all of the following conditions are met:(4 )The licensee ensures that gastrostomy feeding...feeding, hydration and care. This requirement is not met as evidenced by:

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Licensee to ensure that gastronomy feedings are provided to clients as required by Title 22 by submitting proof of training of feeding procedures to staff who provide gastronomy feedings to client by 4/15/24.
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 *** Based on self-reported incident report Licensee failed to provide gastronomy feeding to C1 as required on 4/9/24 while attending the Day Program which poses an immediate health and safety risk to persons 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:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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