576804194-4-25-2024-21-AS-KMOA-D3ZMD6-20240404093033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 576804194
Report Date: 03/21/2024
Date Signed: 04/25/2024 10:56:09 AM

Substantiated

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
03/12/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240312153911

FACILITY NAME:	WOODLAND GARDENS SENIOR LIVING		FACILITY NUMBER:	576804194
ADMINISTRATOR:	GODFREY, ROBERT		FACILITY TYPE:	740
ADDRESS:	240 PALM AVE		TELEPHONE:	(530) 661-0574
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	100	CENSUS: 63	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Lauren Andersen, Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff do not respond to resident call bells in a timely manner

INVESTIGATION FINDINGS:

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****This is an AMENDMENT****
Licensing Program Analyst Jill Nakagawa arrived unannounced to conduct an investigation on the above allegation and to deliver findings. LPA met with Director Lauren Andersen. Facility census on this day is 63.

This Department has investigated the allegations of “staff do not respond to resident call bells in a timely manner”. LPA conducted interviews, reviewed records and made observations.

Continued on 9099C....

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240312153911

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: 03/21/2024

NARRATIVE

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Continued from 9099.....
****This is an AMENDMENT****
The following determinations have been made: LPA interviewed seven (7) of forty-seven (47) staff and fourteen (14) of (63) sixty- three residents and outside parties. It was discovered through interviews, that response times to call bells were reported to take anywhere from 10 minutes to “hours”.

LPA reviewed a sample review of call bell records from 2/6/24, 3/9/24 and 3/16/24 from all three (3) shifts (AM, PM and NOC). Based on LPA’s review LPA found that on 2/6/24 there were over 128 requests for service: one (1) call took over one (1) hour to clear the call bell, six (6) took over thirty (30) minutes and twenty-two (22) calls took fifteen (15) minutes or longer to clear. On 3/9/24 there were 123 requests for service: one (1) call took over one (1) hour to clear, two (2) took over thirty (30) minutes to clear and fifteen (15) calls took over fifteen (15) minutes. Finally, on 3/16/24 there were 134 requests for service: two (2) took over thirty (30) minutes and thirteen (13) took over fifteen (15) minutes to clear. Interviews revealed that due to the long response times some residents were unable to get to the bathroom in a timely manner, left in soiled clothing, unable to get dressed and attend meals in the dining room, or unable to be re-position as needed. In addition, a review of the facility's Resident Handbook, page 2, item 4 Requesting Assistance, it states “If there is an urgent matter or health care emergency please use the emergency call button located in your room."

Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

Appeal rights given. 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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240312153911

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 03/21/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Amended Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs***Based upon records reviewed and interviews conducted, this requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administration to provide a written plan that outlines protocols going forward that will guarantee that sufficient staff are on duty to ensure that all residents' needs are met timely. Plan to be submitted to CCL by POC date of 04/26/2024 to clear the deficiency.
	8 9 10 11 12 13 14	A review of call bell records show that response times were delayed up to 1 hour. This posed an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14	This deficiency was amended.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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