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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200915
Report Date: 10/25/2023
Date Signed: 10/25/2023 02:48:49 PM

Document Has Been Signed on 10/25/2023 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: 3DATE:
10/25/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Javier Arriaga, CaregiverTIME COMPLETED:
03:00 PM
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On 10/25/2023 at 1:50pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPA met with Javier Arriaga, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Alfredo Limjoco via telephone.

LPA conducted a case management visit on 10/06/2023 and cited facility for the following:

  • 80070(b) Client records - LPA observed client records have not been updated and one (1) client file was not available to review. LPA was advised that facility does not handle P & I.
  • 80075(f) Health related services - LPA observed staff have not been first aid certified.
  • 80066(a) Staff records - LPA was not able to review staff records because none was available at the facility.
  • 85076(d)(1) Food service - LPA observed facility did not have a 7-day supply of non-perishable or 2-day of perishable food available for clients.

Continued on LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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: 10/25/2023
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Continued from LIC809.
  • Civil Penalties for 80070(b) in the amount of $900.00 assessed immediately for the period of 10/17/2023 to 10/25/2023.
  • Civil Penalties for 85076(d)(1) in the amount of $900.00 assessed immediately for the period of 10/17/2023 to 10/25/2023.
  • Civil Penalties for 80075(b) in the amount of $900.00 assessed immediately for the period 10/17/2023 to 10/25/2023.

  • Civil Penalties for 80066(a) in the amount of $900.00 assessed immediately for the period 10/17/2023 to 10/25/2023.


The total amount of civil penalties assessed on today's date is $3600.00.

Civil Penalties in the total amount of $3,600.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. A copy the appeal rights, LIC421FC, and the report provided.

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

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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