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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200915
Report Date: 05/16/2024
Date Signed: 05/16/2024 01:08:38 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
05/08/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240508080746
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:
05/16/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nicole Saures, Direct Support ProfessionalTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility does not have an adequate food supply.
INVESTIGATION FINDINGS:
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On 5/16/2024 at 10:15am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and to deliver complaint findings for the allegation above. LPA met with Nicole Suares, Direct Support Professional (DSP) and explained the reason for the visit. Administrator, Alfredo Limjoco, arrived at 12:05pm.

During the investigation LPA interviewed staff and clients. LPA obtained a staff schedule and the food menu. Based on observation LPA did not observe and adequate food supply at the facility. S1 stated what would be cooked for clients for lunch, however, LPA did not observe those food items available at facility.

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.

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

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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 3
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
05/08/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240508080746

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:
05/16/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nicole Saures, Direct Support ProfessionalTIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide adequate food service to clients.
INVESTIGATION FINDINGS:
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4
5
6
7
8
9
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12
13
On 5/16/2024 at 10:15am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and to deliver complaint findings for the allegation above. LPA met with Nicole Suares, Direct Support Professional (DSP) and explained the reason for the visit. Administrator, Alfredo Limjoco, arrived at 12:05pm.

During the investigation LPA interviewed staff and clients. LPA obtained a staff schedule and the food menu. During interviews with clients R1 stated he is satisfied with the food and portions the facility is serving. R2 stated he is satisfied most of the time. LPA did not observe any food being locked or inaccessible to clients.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240508080746
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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2024
Section Cited
CCR
85076(d)(1)
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 (d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable... one week and fresh perishable foods... two days shall be maintained on the premises. This requirement was not met as evidence by:
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Administrator agreed to purchase food and submit photos to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in have 7-day supply of non perishable and 2-day perishables, which poses a potential health and safety risk for 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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3