<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200915
Report Date: 09/20/2024
Date Signed: 09/20/2024 11:47:30 AM

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
09/17/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240917085659
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:
09/20/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Katrina Gaag, Direct Support ProfessionalTIME COMPLETED:
11:10 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are falsifying staff files

Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/20/2024 at 9:50am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegations above. LPA met with Katrina Gaag, Direct Support Professional (DSP) and explained the reason for the visit.

During the investigation LPA interviewed reporting party (RP), staff, client, menu, toured kitchen, reviewed four (4) staff files, and obtained the menu for the week 9/16/2024 to 9/22/2024.

Allegation: Staff are falsifying staff files

RP stated during interview that at this facility staff are falsifying information in staff records. LPA reviewed four (4) staff and did not observe any documentation being

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

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
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 4
Control Number 15-AS-20240917085659
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: 09/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099.

falsified. Based on the investigation the above allegations are unsubstantiated.

Allegation: Staff are not providing adequate food service to residents

RP stated during interview that staff are not providing adequate food to residents. Based on observation and interview with C1 the food that is being provided is adequate. Based on interview with S3 the facility creates a grocery list and does grocery shopping on Friday or Saturday for the following week.

Based upon the information obtained during investigation. The above allegations are 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 violations occurred.

Exit interview conducted and a copy of this report provided.





SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4