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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804194
Report Date: 08/29/2023
Date Signed: 08/29/2023 09:00:34 AM


Document Has Been Signed on 08/29/2023 09:00 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 GARDENS SENIOR LIVINGFACILITY NUMBER:
576804194
ADMINISTRATOR:GODFREY, ROBERTFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: 63DATE:
08/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Caregiver, Erika Ayala
Assistant Living Director, Elka Ralh		TIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Woodland Gardens Senior Living for the purpose of conducting a Case Management-Other inspection. LPA was greeted at the door by Caregiver, Erika Ayala. Assistant Living Director arrived 30 minutes later.

LPA toured the Medication Room to ensure that the room is locked and secured. LPA observed a Medication push cart that was also locked and secured. During the tour of the facility with the Caregiver, LPA observed sufficient staff members in place to attend to residents in placement. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. LPA requested the following documents during today's Case Management-Other Inspection:

-Staff Schedule
-Resident Roster

No deficiencies were observed or cited during today's Case Management-Other inspection. Exit interview was conducted and a copy of this report was given to the Assistant Living Director.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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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