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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804194
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:30:49 PM


Document Has Been Signed on 09/20/2024 03:30 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:LAUREN ANDERSENFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: 65DATE:
09/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alka Ralh, Director of CareTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit for the purpose of inspecting facility for adequate staffing. At the time of inspection, LPA found 2 care staff and 1 med tech caring for 20 residents in the Memory Care (MC) unit and 3 care staff and 1 med tech in Assisted Living (AL), caring for 45 residents.

The facility was clean and orderly. Staff were engaged in providing care. LPA inspected several rooms in AL and found them to be clean with appropriate linens and residents clean and dressed appropriately. During the inspection, an incident was reported to LPA by resident (R1).

According to (R1) interview, a medication technician ( S1) attempted to give (R1) the wrong medication. Per R1, on 09/17/2024 S1 failed to review the identity of the resident or physician's orders for medications and placed the wrong medication in front of R1. R1 indicated that the medication was incorrect and after some discussion S1 removed the medication. In addtion, review of Medication Administration Record (MAR) for residents (R2) and (R3) indicate medications were not dispensed as ordered on 9/17/24 for R2 and 9/18/24 and 9/19/24 for R2 and R3. (See LIC 809-D)

During the inspection of residents' rooms in memory care, LPA observed on two occasions (9/15/24 and 9/20/24) furniture was being used as a restraint to prevent residents from getting out of their beds. In one instance, R4 had a wheelchair pushed against the bed. (Photos taken)


Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 576804194
VISIT DATE: 09/20/2024
NARRATIVE
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Continued from 809.....

LPA was told by staff that another resident would try and pull R4 out of the bed and the furniture was placed next to the bed to detour this from happening. LPA observed resident (R5) with a table, wheelchair, and bedside table pushed against their bed while R5 was in bed. (Photos taken). (See LIC809-D)


The following deficiencies were observed (see LIC 809D) 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 09/20/2024 03:30 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WOODLAND GARDENS SENIOR LIVING
FACILITY NUMBER: 576804194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
HSC
1569.269(a)(6)(a)

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1569.269(a)(6) (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care,
supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications,
and competency to meet tas evidenced by:heir needs.
This requirement is not met
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Facility to send in written plan on how they will meet regulation and meet resident R4's and R5's needs. Facility to send in proof of staff
training.
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Based on 9/15/2024 and 9/20/2024 inspection LPA observed resident R4 and R5 had a wheelchairs and other furnsihings placed in front of their bed to prevent resident from being pulled out of bed by another resident. LPA went over resident personal right and explained staff must be sufficient to observe and meet residents needs. Staff pushed the wheelchair away during the inspections. The licensee did not comply with the section cited above which poses an
immediate health, safety or personal rights risk to persons in care.
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Plan of correction (POC) written statement due 9/23/2024 and proof of staff training due 9/27/2024. POC to be sent to CCL attention LPA Nakagawa by close of business
Type A
09/20/2024
Section Cited
CCR87465(a)(4)

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87465 Incidental Medical and Dental Care(a) A plan... shall be developed... The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced.by.
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Administrator to conduct Medication Administration Training to medication technicians by 9/22/2024. Proof of training to be submitted to CCL, attention LPA Nakagawa by close of business 9/23/2024
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Based on document review and interview with resident R1 Licensee did not comply with the section cited above. R1 did not receive medication as prescribed due to caregiver not verifying the correct resident or the right medication; and medication administration not being documented in MAR for R2 and R3. This poses an immediate health and safety risk to residents 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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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