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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200915
Report Date: 04/13/2023
Date Signed: 04/13/2023 12:27:05 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2023 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20230407112910
FACILITY NAME:WINDSOR RESIDENCE, LLCFACILITY NUMBER:
079200915
ADMINISTRATOR:LIMJOCO, ALFREDOFACILITY TYPE:
735
ADDRESS:3014 WINDSOR DRIVETELEPHONE:
(415) 239-8145
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 2DATE:
04/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Javier Arriaga, Direct Support ProfessionalTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff being verbally abusive to client.
INVESTIGATION FINDINGS:
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On 4/13/2023 at 09:30AM, Licensing Program Analysts (LPAs), L. Hall and L. Alexander arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPAs met with Javier Arriaga, Direct Support Professional (DSP) and explained the reason for the visit. Administrator, Freddie Limjoco, arrived at 9:40AM.

During the investigation LPA interviewed Staff, clients, and reviewed the following documents. S1 scanned he following documents to LPA during visit.: Individual Program Plan (IPP), admission agreement, client notes from date of admission, Medication Administration Record (MAR), dangerous propensity report and physician's report. During interview with C1 it was stated that staff makes noise while he is sleeping aand it upsets him. C1 did not speak of any type of abuse toward any client.

Continued on LIC9099C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20230407112910
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WINDSOR RESIDENCE, LLC
FACILITY NUMBER: 079200915
VISIT DATE: 04/13/2023
NARRATIVE
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Continued from LIC9099.

C2 stated during interview that staff treats the clients nice and that he has never heard the staff disrespect the other client. C2 did state that he is in the community most of the day, but while at the facility everything is ok. All staff stated they have not heard or seen any other staff being abusive towards any client.

Based upon the information obtained during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2