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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804194
Report Date: 02/28/2024
Date Signed: 02/28/2024 03:26:24 PM


Document Has Been Signed on 02/28/2024 03:26 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:
02/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alka Ralh, Resident Care CoordinatorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management inspection and met with Resident Care Coordinator, Alka Ralh..

Facility recently reported that they had a medication error that resulted in a resident receiving the wrong medication. The error was noticed immediately and the proper reporting and monitoring was carried out. PCP and family were notified immediately. Facility transported resident to Emergency Room for observation. The client did not have any adverse effects. Executive Director has conducted trainings to all staff handling medications, and made changes to the medication process that provides additional oversight when medications are passed.

No citations were issued at this time.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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