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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 576804194
Report Date: 02/01/2024
Date Signed: 02/01/2024 05:00:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240108111640
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: 64DATE:
02/01/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lauren Andersen, Executive DirectorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff does not prevent resident from physically and verbally abusing other residents in care.
Staff does not provide a safe environment to residents in care.
INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 2/1/24 at approximately 1:40 PM to conduct an investigation and deliver findings on the above allegations.

LPA met with Executive Director, Lauren Andersen, to review the findings.

(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20240108111640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/01/2024
NARRATIVE
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****Report has been amended****

The allegations state that Staff does not prevent resident from physically and verbally abusing other residents in care and Staff does not provide a safe environment to residents in care. The reporting party stated that R1 has been continuously threatening and harassing multiple residents; residents have been asking staff to help them but say until he's violent there is nothing that can be done and R1 is intimidating to many....sabotages games....explodes in anger...barges in rooms without permission...uses foul language.

LPA made observations, conducted interviews and reviewed records. LPA's review of records found that there had been no formal complaints made by residents to administrator of the facility regarding R1, although both residents and staff mentioned that there were multiple informal conversations between staff and residents R2 and R3 about R1. Observations made by LPA on several occasions, including 9/20/2023, 1/9/2024 and 2/1/2024 did not find any behaviors that would be considered harassing, intimidating or violent. R1 was observed with pet, which was well cared for and did not exhibit any signs of neglect or mistreatment. Interviews with staff and residents indicate that there are 2 or 3 residents who do not get along and find discomfort in being together, however, it was observed that they do attend activities at the same time, and occasionally use inappropriate language but with redirection by staff, can maintain civility towards one another. It has been reported that R1 and R2 socialize together quite a bit. LPA has observed the same with no signs of threatening behaviors or intimidation. LPA has been told by staff that there are residents who do not get along but staff are aware and able to redirect residents: there have been no episodes of harassment or violence, but rather unkindness and misunderstandings.

Although the allegations may be true, based on observations, statements and documents, there is not a preponderance of evidence to prove the allegations true or false therefore the complaint is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2