Community Care Licensing

Document Has Been Signed on 08/05/2024 04:16 PM - It Cannot Be Edited

FACILITY NAME:	WINDERMERE AT WHITMAN		FACILITY NUMBER:	079201175
ADMINISTRATOR/ DIRECTOR:	WARD, WHITNEY		FACILITY TYPE:	740
ADDRESS:	1921 WHITMAN RD.		TELEPHONE:	(415) 710-5169
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY: 6		CENSUS: 4	DATE:	08/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:10 PM
MET WITH:	Sureshkumar Reddy		TIME VISIT/ INSPECTION COMPLETED:	04:35 PM

SUPERVISORS NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type A

Section Cited

CCR

87208(a)(2)

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (2) A copy of the Admission Agreement, containing basic and optional services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	new

Type A

Section Cited

HSC

1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by the staff who are working do not have CPR training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	Cleared during visit.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type A

Section Cited

CCR

87355(d)(3)

(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 2 staff does not have fingerprints cleaence which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	Facility staff was removed from the facility Civil penalty was assessed on this day for $200

Type A

Section Cited

CCR

87555(b)(26)

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having nonperishable foods for a minimum of one week and perishable foods for a minimum of two days which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	The facility agrees to buy nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Proof of correction will be sent to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not locking the medication cabinet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The facility agrees to lock the medication cabinet. The facility also agrees to review the regulation and submit a self certification letter to CCLD by POC date.

Type A

Section Cited

CCR

87618(b)(3)(B)

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having a “No Smoking-Oxygen in Use” signs on residents door which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	Cleared during visit

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type A

Section Cited

CCR

87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a knife and scissors left unlocked in drawer which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	Cleared during visit.

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having cough medication left in the fridge which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	Cleared during visit

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above old furniture in the shed and side yard which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The facility agrees to clean up the shed and side yard. Proof of correction will be sent to CCLD by POC date.

Type B

Section Cited

CCR

87307(a)(3)(B)

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having furniture in room 5 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The facility agrees to buy furniture for room 5. Proof of correction will be sent to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type B

Section Cited

CCR

87413(a)(1)

(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above by not having coverage for regular staff who are absent which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The facility also agrees to review the regulation and submit a self certification letter to CCLD by POC date.

Type B

Section Cited

HSC

1569.618(a)

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having an updated LIC 500 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	Facility agrees to submit an updated LIC 500 to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type B

Section Cited

CCR

87355(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not getting S2 records cleaence transfered to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	The Staff was removed from the facility. Facility agrees to request a transfer, or obtain new fingerprint clearence proir to any new staff member working at the facility. The facility also agrees to review the regulation and submit a self certification letter to CCLD by POC date.

Type B

Section Cited

CCR

87219(a)(1)

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, the resident in room 1 was watching a screen saver because the remote was out of reach and staff had not checked on her, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The facility agrees to review the regulation and submit a self certification letter to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type B

Section Cited

CCR

87555(b)(23)

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having cooked rice left in a rice cooker that was stored in a cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	Cleared during visit

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having a fire drill since 10/2/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The facility also agrees to review the regulation conduct a fire drill. Proof of correction will be sent to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

Link to Parent Document Below:

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2024

Type B

Section Cited

CCR

87705(h)

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having a latch on the gate in the side yard which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The facility also agrees to repair the gate. Proof of correction will be sent to CCLD by POC date.

Type B

Section Cited

CCR

87705(j)

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having alarms that would sound when the doors opened which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The facility also agrees to replace or repair the alarms. Proof of correction will be sent to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024

FACILITY NAME: WINDERMERE AT WHITMAN	FACILITY NUMBER: 079201175
	VISIT DATE: 08/05/2024