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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804194
Report Date: 08/25/2023
Date Signed: 08/25/2023 02:02:14 PM


Document Has Been Signed on 08/25/2023 02:02 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WOODLAND GARDENS SENIOR LIVINGFACILITY NUMBER:
576804194
ADMINISTRATOR:ANDERSON, LAURENFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: 63DATE:
08/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Lauren Andersen, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted a pre-licensing inspection on 08/25/23 for this change in ownership application. LPA met with Lauren Andersen, Administrator of currently-operating facility.

The facility will operate as an RCFE for a total of 100 non-ambulatory residents providing assisted living and memory care. Facility will operate with 24 hour staffing and Applicant will ensure sufficient staffing at all times. The facility is one level, with resident rooms, an activities room, living room, dining room, kitchen, medication room, laundry room with storage room, and a memory care unit with dining/activities room and resident bedrooms. There are secure outside areas for residents to enjoy, as well.

LPA observed the following items: locked storage areas for medications, locked storage for toxins and cleaning supplies, all exits were unobstructed, a First Aid Kit, night lights and flashlights for emergency lighting, an ample supply of linens, paper products and hygiene supplies, grab bars and non-slip mats in bathrooms, Fire Extinguishers charged and serviced on 01/24/2023, required furnishings in bedrooms, required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy),
and water temperature was tested during inspection and LPA observed readings within regulation of 105-120 Degrees F in 10 out of 10 rooms.

Upon fire clearance by the Fire Department the Pre-Licensing inspection will be complete. LPA found no concerns/deficiencies during inspection.
The Component III Orientation was completed.


SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
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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