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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200915
Report Date: 02/28/2024
Date Signed: 02/28/2024 02:11:49 PM

Substantiated


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
11/21/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231121160903
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:
02/28/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:David Garcia, Direct Support ProfessionalTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility staff are not properly dispensing medication as prescribed.
INVESTIGATION FINDINGS:
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On 2/28/2024 at 12:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Alex David Garcia, Direct Support Professional, and explained the reason for the visit.

Allegation: Facility staff are not properly dispensing medication as prescribed.

RP stated facility staff tries to give prescribed medication to client even though client refuses. C1 stated during an interview that he refuses medication, but staff continue to offer medication. The other two (2) clients stated during interviews that there had not been a problem with the medication. S1 stated that C1 has refused medication for

Continued LIC9099C


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

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
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 6
Control Number 15-AS-20231121160903
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: 02/28/2024
NARRATIVE
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Continued from LIC9099.

months, and now there is not a medication administrative record (MAR) or medication kept at the facility for C1. S2 was not able to provide any records regarding C1’s medication.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20231121160903
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2024
Section Cited
CCR
80075(k)(7)
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80075 (k) The following requirements shall apply to medications which are centrally stored (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year... This requirement was not met as evidence:
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Administrator gave a copy of C1's MAR to CCLD on today's date. Deficiency cleared during visit.
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Based on record review the Licensee did not comply with the section cited above in keep a MAR for C1's medication, which poses 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
11/21/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231121160903

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:
02/28/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:David Garcia, Direct Support ProfessionalTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility staff are not adhering to food service guidelines

Facility staff do not treat client with respect

Facility staff interfere with client's sleep by playing loud music

Facility staff interacted with client in an inappropriate manner
INVESTIGATION FINDINGS:
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On 2/28/2024 at 12:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with David Garcia, Direct Support Professional, and explained the reason for the visit.

During the course of the investigation, LPA interviewed three (3) clients and staff.

Allegation: Facility staff are not adhering to food service guidelines

Reporting party (RP) stated that the food is unhealthy that the clients are given, but the staff is following the menu that is posted. C1 stated during interview that he doesn't like the food that is cooked by staff and meals are what staff likes to eat. The other two

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20231121160903
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: 02/28/2024
NARRATIVE
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Continued from LIC9099.

(2) clients stated they do not always care for the food but it is okay. C2 stated he buys most of his food because he likes too not because there isn't any. C3 states he is not at the facility most of the time so the food is fine for him. LPA obtained a copy of the monthly food menu during today's visit. Based on the investigation the above allegations are unsubstantiated.

Allegation: Facility staff do not treat client with respect



RP stated during initial interview that staff harass clients by hitting the bedroom door during cleaning which is not showing the clients respect. During interviews with clients none stated that staff hit their doors while cleaning. S1 stated there is one (1) client that stays wake all night until early morning and then complains when the staff if vacuuming and cleaning. S2 and S3 stated that there has been a time when the clients' door is bumped or hit but it is not intentionally done.

Allegation: Facility staff interfere with client's sleep by playing loud music

RP stated during initial interview that the staff plays loud music all day and night.
C1 stated that staff plays music and he is unable to sleep at night. The other two (2) clients stated the staff sometimes plays music during the day. C3 stated if he wanted to nap and feels the music is loud he just ask the staff to turn it down and it's not a problem. S2 stated staff do play music during the day but it isn't that loud.

Allegation: Facility staff interacted with client in an inappropriate manner

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20231121160903
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: 02/28/2024
NARRATIVE
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Continued from LIC9099C.

RP stated during initial interview that staff got into one of the client's face and impersonating the client. During the interviews with the clients none spoke of
any of the staff impersonating them or getting in their face. S1 stated one (1) client has an issue when you ask him to do something and feels that he is being picked on at times. S1 stated there has not been an issue with two (2) of the clients at all. S1 also stated he has not observed or been told that any staff have treated clients inappropriately. S2 and S3 stated they have not observed any client being treated inappropriately by another staff.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6