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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200915
Report Date: 07/30/2024
Date Signed: 07/30/2024 01:39:34 PM

Document Has Been Signed on 07/30/2024 01:39 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WINDSOR RESIDENCE, LLCFACILITY NUMBER:
079200915
ADMINISTRATOR/
DIRECTOR:		LIMJOCO, ALFREDOFACILITY TYPE:
735
ADDRESS:3014 WINDSOR DRIVETELEPHONE:
(415) 239-8145
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 2DATE:
07/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Nicole Saures, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On 7/30/2024 at 12:15pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 7/25/2024. LPA met with Nicole Saures, Direct Support Professional. Administrator, Alfredo Limjoco, arrived at 12:40pm, and LPA explained the purpose of the visit.

The incident occurred on 7/24/2024 at approximately 6:00pm involved a client being given a meal containing a food that gave the client an allergic reaction. The incident report stated that the staff mislabeled the dinner plate and caused the client to have a reaction. During the visit LPA reviewed the menu that was posted and dated 7/22/24 - 7/28/24 and observed there wasn't any seafood item on the menu. S1 stated facility have been meal prepping dinner for five (5) days and one of the clients' requested seafood to be added to their meal.


LPA L. Hall collected the menu posted.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 07/30/2024 01:39 PM - It Cannot Be Edited


Created By: Laura Hall On 07/30/2024 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WINDSOR RESIDENCE, LLC
FACILITY NUMBER: 079200915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2024
Section Cited
CCR
80072(a)(3)

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80072 (a) ...each client shall have personal rights which include, but are not limited to... (3)To be free from.. infliction of pain, humiliation, or other actions of a punitive nature, including...: interference with the daily living functions, including eating... This requirement was not met as evidence by:
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The administrator agreed to have all staff take a food handling and safety class and submit certification to CCLD by POC.
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Based on observation and interview the Licensee did not comply with the section cited above in keeping the client free from interference with daily living which poses a potential health and safety risk to persons in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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