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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200915
Report Date: 10/06/2023
Date Signed: 10/06/2023 02:48:40 PM

Document Has Been Signed on 10/06/2023 02:48 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:LIMJOCO, ALFREDOFACILITY TYPE:
735
ADDRESS:3014 WINDSOR DRIVETELEPHONE:
(415) 239-8145
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 2DATE:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Villa Lucila Cabuhat, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/6/2023 at 12:40pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Villa Lucila Cabuhat, Caregiver, and explained the purpose of the visit. Co- Administrator, Alexander Tecson, arrived at 1:05pm. The administrator currently holds a certificate (#6048327735) that expires on 05/20/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2 ) bathrooms. One (1) bedroom being used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 141.6 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 5/17/2022. Fire drill last conducted 10/2/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/06/2023
NARRATIVE
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Continued from LIC809.

Facility did not have any staff files available for review. One (1) client file was missing the physician's report and the other client file was not available for review. P & I was not available for review. .

The following forms to be updated and submitted to CCLD by 10/13/2023:
  • LIC610D Emergency disaster plan (last page)
  • Liability insurance.
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources


LPA observed the following deficiencies:
  • At 12:50pm, LPA observed during record review that S2 was not associated to the facility.
  • At 1:00pm, LPA observed facility did not have a 7-day non perishable and 2-day perishable supply of food available for clients.
  • At 1:05pm, LPA observed hot water measuring at 141.6.
  • At 1:25pm, LPA observed during record review that C1 was missing the physician's report and C2 did not have a file available for review.
  • At 1:25pm, LPA observed during record review that the P & I was not at facility and available for review.
  • At 1:30pm, LPA observed during record review no staff files were available for review.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/06/2023
NARRATIVE
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Continued from LIC809C.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, 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.

*An immediate $500.00 civil penalty will be assessed on today's date for association.*

Exit interview conducted. A copy of the LIC421BG, this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/06/2023 02:48 PM - It Cannot Be Edited


Created By: Laura Hall On 10/06/2023 at 02:09 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: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having hot water over 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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Administrator agreed to adjust water temperature between 105 - 120 and submit photo with running water to CCLD by POC date.
Type A
Section Cited
CCR
80019(e)(3)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

(3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, and record review, the licensee did not comply with the section cited above in having S2 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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Administrator submitted the LIC9182 and a copy of S2's identification to LPA during visit. Deficiency cleared.
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: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/06/2023 02:48 PM - It Cannot Be Edited


Created By: Laura Hall On 10/06/2023 at 02:09 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: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having staff first aid certified which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator will have all staff first aid certified and submit certification to CCLD by POC date.
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having client records complete and available for review including P & & which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator agreed to complete both clients file and submit self-certification that the files are complete, and submit copies of P & I to CCLD by POC date.
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: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2023 02:48 PM - It Cannot Be Edited


Created By: Laura Hall On 10/06/2023 at 02:09 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: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having 7-day perishable and 2-day non perishable foods for clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Administrator agreed to purchase food and submit photo of food and receipt to CCLD by POC date.
Type B
Section Cited
CCR
80066(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having staff records available for review at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator agreed to complete staff records and submit a self-certification that the records are complete to CCLD by POC date.
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: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
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