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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804194
Report Date: 09/12/2023
Date Signed: 09/12/2023 04:44:56 PM


Document Has Been Signed on 09/12/2023 04:44 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:GODFREY, ROBERTFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: 63DATE:
09/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Lauren Andersen, Program DirectorTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and investigate an incident report regarding a resident (R1) exhibiting some non-compliant behaviors. LPA conducted interviews, requested documentation and made observations.

It appears that R1 is new and having some issues transitioning into the community and understanding how facilities operate, including house rules. On 8/14/23, R1 was smoking outside. Staff discovered a small pile of dry grass burning at the edge of the sidewalk in the smoking area by R1. Staff was able to extinguish. No damage was sustained. Administrator has reviewed smoking area protocols with all residents and staff, including R1.

Program Director is working with R1 to assimilate into community.

No deficiencies found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
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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