Other·August 13, 2019

PRINTED: 05/14/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA030000008 (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COTTONWOOD HEALTHCARE CENTER 625 Cottonwood Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A000 Initial Comments ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A000 The following reflects the findings of the California Department of Public Health during a staffing visit: Representing the Department: T.A., Associate Governmental Program Analyst. Welfare and Institutions (W&I) Code section 14126.022 sets forth the Department's authority to conduct audits of direct caregiver nursing services provided to residents of skilled nursing facilities, and to establish procedures for conducting such audits through All Facility Letters (AFLs). W&I Code section 14126.022 is attached hereto and incorporated herein as 'Attachment A.' AFL 11-19, setting forth the audit process and guidelines for facilities is available through the following link: http://www.cdph.ca.gov/certlic/facilities/Docum ents/LNC-AFL-11-19.pdf. Health and Safety Code (HSC), setting forth the requirements for Certified Nurse Assistants is available through the following link: http://www.leginfo.ca.gov/cgi-bin/displaycode? section=hsc&group=01001-02000&file=13371338.5 A029 1276.5(a) HSC Section 1276 A029 (a) The department shall adopt regulations setting forth the minimum number of equivalent nursing hours per patient required in skilled Licensing and Certification Division LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 9SGI11 TITLE (X6) DATE If continuation sheet 1 of 3 PRINTED: 05/14/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA030000008 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COTTONWOOD HEALTHCARE CENTER 625 Cottonwood Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE nursing and intermediate care facilities, subject to the specific requirements of Section 14110.7 of the Welfare and Institutions Code. However, notwithstanding Section 14110.7 or any other provision of law, commencing January 1, 2000, the minimum number of actual nursing hours per patient required in a skilled nursing facility shall be 3.2 hours, except as provided in Section 1276.9. This Statute is not met as evidenced by: Based on record review and interview, the above nursing facility was found out of compliance with Health and Safety Code 1276.5(a), the requirement for a minimum of 3.2 nursing hours per patient day for 2 out of 24 randomly selected days from July 01, 2017 through September 30, 2017: Findings: · The total number of actual nursing hours performed by direct caregivers per patient day divided by the average census during the patient day failed to meet 3.2 Nursing Hours per Patient Day per AFL 11-19, Section 2(a-c). · Facility failed to replace staff that did not work as scheduled, and/or did not schedule to meet a minimum of 3.2 Nursing Hours per Patient Day. As a result, the total number of actual nursing hours performed by direct caregivers per patient day divided by the average census during the patient day failed to meet 3.2 Nursing Hours per Patient Day per AFL 11-19, Section 2(a-c). DATE NHPPD 07/23/2017 2.94 08/12/2017 3.13 Licensing and Certification Division STATE FORM 6899 9SGI11 If continuation sheet 2 of 3 PRINTED: 05/14/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA030000008 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 06/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COTTONWOOD HEALTHCARE CENTER 625 Cottonwood Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensing and Certification Division STATE FORM 6899 9SGI11 If continuation sheet 3 of 3