The Woodlake

Allegation investigated: Staff did not properly report incidents involving a resident

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection at the Woodlake RCFE on 8/19/26 at 11:40am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator, Latrice Ross and together discussed the investigation details. Based on the interviews conducted during the investigation process and other information obtained during the investigation process, LPA Gould was unable to corroborate the allegation. LPA conducted interviews with reporting Party (RP) and facility Administrator. Per administrator statements, once it was determined two residents had departed the facility unsupervised, the facility contacted local law enforcement to make a missing person report. Police arrived while the administrator was on the phone with the authorized representatives for one of the two individuals (R1) who had eloped from the facility. Officers who responded to the request for missing persons and obtained the contact information for the other missing individual’s (R2) authorized representative. Unsubstantiated After being contacted by law enforcement, the authorized representative for R2, prior to being contacted by the facility, called the facility directly to gather additional information regarding R2’s elopement from the facility and current status. Authorized representative questioned the timeliness of the facility notification policy, rather than being called by law enforcement directly. LPA Gould has determined the facility has met requirements for reporting to law enforcement prior to contacting authorized representatives to report and incidents such as elopement. Facility was in process of making notifications when R2’s authorized representative contacted the facility and was able to discuss the circumstances of elopement. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Reporting Requirements are unsubstantiated but if any additional information is received this complaint can be amended and the findings can be changed. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 27-AS-20260227111615

Allegation investigated: Staff do not safeguard resident's personal items. Staff did not meet residents needs. Staff did not assist resident with Activities of Daily Living (ADLs). Staff did not accord resident with dignity and respect. Staff retaliated against a resident. Staff did not prevent a resident from harassing other residents. Administrator did not address multiple complaints against a staff member.

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct a complaint investigation and to deliver findings for the allegations mentioned above. Based on interviews, records reviewed, and information obtained, the allegations could not be corroborated. Safeguarding personal items, records and staff interviews indicate R1 vacated on March 30, 2026, and housekeeping performed standard room turnover. Staff reported only perishable food items were discarded. No evidence was found indicating non-perishable personal property was improperly disposed of. As it relates to ADL assistance, dignity, respect, and retaliation, interviews with staff and residents did not support RP’s statements. Unsubstantiated No documentation or witness accounts corroborated claims that staff prevented ADL assistance, refused care, retaliated against R1, or encouraged false complaints. As it relates to the allegation resident harassment, interviews indicated staff intervene as needed. No evidence was found that the Administrator failed to address safety concerns. Complaints against staff, internal logs did not show substantiated findings or patterns of neglect by management. Although the concerns may have occurred or may be valid to some degree, there is not a preponderance of evidence to prove that staff failed to safeguard personal items, meet resident needs, assist with ADLs, provide dignity and respect, prevent resident-to-resident harassment, retaliate against R1, or that the Administrator failed to address complaints. All allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 27-AS-20260401150548

Allegation investigated: Staff did not prevent another resident from injuring a resident

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct a complaint investigation into the allegations mentioned above. LPA met with the Administrator and explained the purpose of the visit. On 03/14/2026, Community Care Licensing (CCL) received a cross report from Adult Protective Services (APS) regarding SOC 341 Report ID 267329. The report stated that R1 was transported by ambulance to UC Davis Medical Center after another resident pushed her, causing her to fall and strike her head on the floor. It was reported that R1 experienced pain to her forehead, nose bridge, and abdomen. Law enforcement and R1’s spouse was notified. Substantiated During the investigation, LPA obtained and reviewed the facility’s Administrator Report dated 03/13/2026, which documented that staff witnessed R2 push R1 in the hallway, causing R1 to fall to the floor. Staff noted mild redness to the back of R1’s head and assisted her from the floor. Vital signs were stable. R1 was transported to UC Davis Medical Center for evaluation. Hospital documentation indicated R1 was assessed for possible neck injury; MRI/scan results did not identify acute injury, and R1 returned to the facility with no new treatment recommendations. Although staff responded after the fall, the facility did not demonstrate that adequate supervision or preventive measures were in place to protect R1 from resident-to-resident aggression. The Administrator Report confirms staff witnessed the push as it occurred, indicating the altercation was not prevented. The facility did not provide documentation showing proactive monitoring, behavioral interventions, or supervision sufficient to prevent the incident before physical contact occurred. Based on the SOC 341 report, Administrator Report, hospital documentation, and interviews, the facility failed to protect R1 from a foreseeable health and safety hazard. Therefore, the allegation that staff did not prevent another resident from injuring R1 is substantiated.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 27-AS-20260316101557

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 15, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by records and interviews that R2 pushed R1 to the floor, causing R1 to go to the ER for evaluation. A potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: The Facility has conducted an in service to address the behavior challeges of R2 and has established a plan to provide R2 with additional support.

Allegation investigated: ) Staff allowed a resident to wander from the facility.

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at The Woodlake RCFE on 3/9/26 at 11:45am to inform the licensee of complaint allegation mentioned above. Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated based on interviews with staff and review of facility files, and incident reports submitted to the department. LPA has determined two residents did elope from the memory care area of the facility and were in the community without appropriate supervision or supports. Per staff statements, the facility staff responded to the door alarm being activated and assumed the resident present at the door was the resident who activated the alarm. Per staff statements no perimeter or internal search was conducted until residents were noticed to be missing from dinner services. 911 was immediately notified and residents were found and returned to the facility. Report continued on LIC 9099-C. Substantiated The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of neglect/lack of supervision is substantiated but if any additional information is received this complaint can be amended and the finding can be changed. The following deficiencies are cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 9, 2026 · control 27-AS-20260227111615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 11, 2026

Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by staff statements and incident reports that residents were able to elope from facility and were in the community unsupervised for several hours until returned to the facility by law enforcement which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 9, 2026

Plan of correction: Facility has agreed to provide a written plan of correction detailing the steps facility has taken to ensure the issue does not reoccur.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 3/9/26 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management incident report to address received incident reports regarding missed medications. LPA met with S1 and S2 to discuss reported missed medications by residents. Per staff statements there have been ongoing issues with contracted pharmacy as the pharmacy was undergoing internal disruptions and changes that affected medication delivery. Per staff statements they are currently still under contract but are evaluating options going forward. Per California code of regulations, title 22, no deficiencies were issued during today's inspection and additional follow up may be required to make a determination regarding the reported incidents. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 9, 2026

Type of visit: Office

On 7/24/25 at 1:00pm LPA Kevin Gould conducted a component III Orientation via Microsoft Teams with applicant Dan Williams for The Woodlake RCFE. LPA and Applicant discussed all aspects of the component III orientation for RCFE: •Article 4 – Operating Requirements •Article 5 – Physical Environment •Article 7 – Personnel •Article 8 – Resident Records •Article 11 – Health Related Services & Conditions •Article 12 – Dementia LPA Gould has already completed the pre-licensing inspection with no observed or cited deficiencies during the inspection. At the time of this report the applicants have met all requirements to be licensed. LPA has no objections to the facility being licensed. A copy of this report will be set to the applicant for signature.the state’s words, verbatim · CDSS document, Jul 24, 2025

Type of visit: Prelicensing

On 7/17/25 at 9:30am Licensing Program Analyst (LPA) Kevin Gould arrived at The Woodlake for the purpose of conducting a required Change of Ownership Pre-licensing Inspection. LPA met with Administrator, Corinna Goode and together conducted a tour of the facility. The current census is 122. The facility has a secured Memory Care with a current census of 38. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 116 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. Per California Code of Regulations, Title 22 there were no deficiencies noted or cited during today's inspection. LPA has contacted the applicant to complete the Component III orientation. Once complete, LPA will have no objections to the facility being licensed. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 17, 2025