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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200915
Report Date: 12/04/2024
Date Signed: 12/04/2024 04:12:32 PM

Document Has Been Signed on 12/04/2024 04:12 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/
DIRECTOR:		LIMJOCO, ALFREDOFACILITY TYPE:
735
ADDRESS:3014 WINDSOR DRIVETELEPHONE:
(415) 239-8145
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 2DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Katrina Gaag, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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On 12/4/2024 at 2:25pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Katrina Gaag, Direct Support Professional, and explained the purpose of the visit. LPA spoke with Administrator, Alfredo Limjoco via telephone for approval to have staff sign documents. The administrator currently holds a certificate (#7016087735) that expires on 05/20/2026. 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) bedrooms and two (2) bathrooms. One (1) bedroom occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 68 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 128.1 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 purchased on 8/19/2024. Emergency disaster plan last updated on 9/1/2024. Fire drill last conducted 11/3/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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: 12/04/2024
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Continued from LIC809.

LPA reviewed five (5) staff file all were current and complete. LPA reviewed one (1) client file. One (1) client did not have a file.

The following forms to be updated and submitted to CCLD by 12/11/2024:
  • LIC610D Emergency disaster plan (last page)
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources


LPA observed the following deficiencies:
  • At 2:50pm, LPA observed during record review that C1 was missing the physician's report and the appraisal needs and services plan.
  • At 2:50pm, LPA observed during record review that C2 did not have a file to review.
  • At 3:30pm, LPA observed facility did not have the quantity of linen required. LPA observed two (2) bath towels and two (2) hand towels.


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.

Exit interview conducted. A copy of the appeal rights and this report provided.


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

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2024 04:12 PM - It Cannot Be Edited


Created By: Laura Hall On 12/04/2024 at 03:48 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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(A)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (A) The quantity of linen provided shall permit changing the linen at least once each week or more often when necessary to ensure that clean linen is in use by clients at all times.

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 a quantity of linen required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Administrator agreed to purchase bedding and towels and submit photo of receipt and items to CCLD by POC date.
Type B
Section Cited
CCR
80070(a)
80070 Client Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

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 a complete file for C1 and a file for C2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Administrator agreed to complete both files and submit documents 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: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


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