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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804194
Report Date: 06/04/2024
Date Signed: 06/04/2024 02:46:11 PM


Document Has Been Signed on 06/04/2024 02:46 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WOODLAND GARDENS SENIOR LIVINGFACILITY NUMBER:
576804194
ADMINISTRATOR:LAUREN ANDERSENFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: 66DATE:
06/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Alka Ralh, Assisted Living DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nakagawa and Macias conducted an unannounced case management inspection and met with Alka Ralh, Assisted Living Director.

At approximately 12:00pm, LPAs Nakagawa and Macias conducted a tour of the Memory Care Facility and found the Medication stored room to be wide open, unsecured, with no staff present, accessible to residents in care (deficiency cited, see 809D). LPAs also observed Memory Care Residents restroom cabinets to be unsecured with toxins accessible to residents.

Facility is being cited per Regulation 87465(h)(2) and 87705(b)(2).

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. 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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline MaciasTELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
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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Document Has Been Signed on 06/04/2024 02:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/04/2024
Section Cited
CCR
87465(h)(2)

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87465(h)(2)Medical and Dental Care:(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines... not accessible to persons other than employees responsible for the supervision of the centrally stored medication...
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Administrator to ensure medications are not accessible to residents by keeping Medication Room locked at all times. Administrator to submit in-service Training reviewing Regulation for all staff with the following information:
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This is evidenced by : Based on LPA's observations medication room was unlocked with medications unsecured without staff present while Residents were having lunch which poses a potential health, safety or personal rights risk to persons in care.
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A plan for immediate In-service Training date, In-service topic submitted by POC date of 6/5/2024 to LPA and Training Roster with signatures and job role to LPA by POC date of 6/11/2024.
Type A
06/04/2024
Section Cited
CCR87705(b)(2)

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87705(b)(2) Care of Persons with Dementia: (b) In addition to the requirements as specified in ....the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Administrator to ensure all cabinets are functioning and ensure all employees have keys to the cabinets. Administrator to submit a statement stating corrections are being completed by POC due date of 6/5/2024.
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This is evidence by: Based on LPAs observation, 4 out of 6 cabinets in Residents bathroom were unsecured with toxins, which poses an immediate health, safety or personal rights risk to persons in care.
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Administrator to review Regulation for all staff regarding Care of Persons with Dementia.
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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline MaciasTELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
LIC809 (FAS) - (06/04)
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