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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201175
Report Date: 07/12/2023
Date Signed: 07/12/2023 10:16:24 AM

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
07/07/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230707171459
FACILITY NAME:WINDERMERE AT WHITMANFACILITY NUMBER:
079201175
ADMINISTRATOR:WARD, WHITNEYFACILITY TYPE:
740
ADDRESS:1921 WHITMAN RD.TELEPHONE:
(415) 710-5169
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 4DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:TIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Resident sustained unexplained bruising while in care
INVESTIGATION FINDINGS:
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On 07/12/2023 at 09:04 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct an initial 10-day complaint visit. LPA met with Administrator Whitney Ward explained the purpose of the visit.

During the initial 10-day complaint visit. LPA interviewed staff, they stated that R1 was admitted to the facility on 06/27/2023 and on 06/28/2023 staff noticed brusing on her right hand. They informed the administrator who noticed it was an old bruse and assumed the family was aware of it and did not inform them.

Based on LPA’s interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.

The Facility was cited, and citations can be found on the LIC 9099-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 15-AS-20230707171459
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: WINDERMERE AT WHITMAN
FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2023
Section Cited
CCR
87468.1(a)(8)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:To have their representatives regularly informed by the licensee of activities related to care or services, ...as appropriate to their needs. This requirement is not met as evidenced by:
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The facility agrees to review the regulations on informing the resident representives on the care or services of the residents. Proof of correction will be sent to CCLD by POC date.
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The facility not informing the family of brusing that was observed on the residents hand
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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: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
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