Woodland Home

Type of visit: Required - 1 Year

On 12/08/2025 at 11:15AM, Licensing Program Analysts (LPAs) Andrew Christy and David Doidge arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Lead Staff Alexandria Jackson, and explained the purpose of the visit. Administrator Denise Mansfield arrived at XXX. The facility currently houses three (3) residents with a max capacity of four (4) residents. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 70.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 105.0 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 05/08/2025. At 12:45PM, LPA reviewed three (3) resident files and five (5) staff files, all found to be complete. The emergency disaster plan was last reviewed 12/08/2025. Quarterly emergency drills were last conducted 11/10/2025. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. Resident P&I Log was reviewed and there were no outstanding errors. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Dec 8, 2025

Allegation investigated: Staff do not provide appropriate showering equipment for a resident Staff do not meet the residents showering needs Staff are sleeping during the night shift Staff are not providing adequate care and supervision to the residents Staff are not meeting the residents diapering needs Staff are being treated with ammonia Staff mishandled the residents medications

On 7/03/25 at 10:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegations above. LPA met with Denise Mansfield, Administrator and explained the purpose of the visit. During the course of the investigation LPA interviewed W1, facility staff, toured facility and reviewed facility records. Allegation: Staff do not provide appropriate showering equipment for a resident W1 alleged that R1 did not have adequate equipment in his bathroom to shower safely. Facility staff (S1 & S2) stated that there are no issues with R1 using the shower safely. R1 has his preferred shower which he uses with minimal assistance. LPA observed R1’s shower to be adequately furnished with grab bars and shower chair. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Allegation: Staff do not meet the residents’ showering needs S1 and S2 stated that all the residents are on a showering schedule and receive at least 3 showers a week and more as needed. LPA reviewed residents’ care notes that indicate showers happen according to schedule. Allegation: Staff are sleeping during the night shift S3 and S4 work the overnight shifts at the facility. Both S3 and S4 denied ever seeing staff sleep on the overnight shift. S1 also stated that she has never received a complaint about staff sleeping while on duty except from W1. S1 investigated W1’s allegation and found it not to be true. Allegation: Staff are not providing adequate care and supervision to the residents Interviews with facility staff revealed that they all felt that there are enough staff to provide adequate care and supervision for the residents. During waking hours there are 3 staff on duty for the 4 residents along with the House Manger and Administrator. Allegation: Staff are not meeting the residents’ diapering needs S1 and S2 stated that the incontinent residents at the facility are changed every 3 hours or more as needed. LPA observed the residents to be clean, nicely dressed and free of odor. The facility was also free of odor. Facility staff also reported that they change the residents diapers as scheduled or when the residents’ have a need. Allegation: Staff are being treated with ammonia W1 stated that the residents’ diapers smell like ammonia and that she suspects staff are using ammonia to clean residents. All facility staff deny ever using ammonia to clean the residents. LPA observed the residents to be clean, well dressed and odor free. Inspection of the facility revealed that there is no ammonia on site. Allegation: Staff mishandled the residents’ medications W1 couldn’t remember any specific incidents when medication was mismanaged but wanted LPA to check into it. LPA interviewed staff and reviewed medication administration records (MARS) for January, February and March 2025 and found no irregularities. This agency has investigated the above allegations, we have found that the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 15-AS-20250320145107

Type of visit: Required - 1 Year

On 12/20/2024 at 10:00 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Tatiana Flores, DSP, and explained the purpose of the visit. Lead Staff supervisor, Alexandria Jackson, arrived at 11:41 AM. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms 3 of which are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 92 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. First aid kit was observed to be complete. Fire extinguisher was last serviced on 05/14/2024. Fire drill was last conducted on 12/06/2024 and are conducted monthly. LPA reviewed 3 residents records and 5 staff records all were complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 20, 2024

Type of visit: Required - 1 Year

On 12/21/2023 at 9:00 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Lead Staff, Alexandria Jackson and explained the purpose of the visit. Administrator arrived at 9:38 AM. The facility’s fire clearance was approved for 4 Non-Ambulatory. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which all 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. First aid kit was observed to be complete. Fire extinguisher was last serviced on 05/18/2023. Fire drill was last conducted on 12/05/2023. At 9:20 AM, LPA reviewed 4 of 4 residents records. At 10:25 AM, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. At 11:17 AM, LPA reviewed a sample of 4 of 4 resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 21, 2023