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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208930
Report Date: 11/16/2020
Date Signed: 11/16/2020 12:55:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:WINDHAM, THEFACILITY NUMBER:
107208930
ADMINISTRATOR:METZ, KELLYFACILITY TYPE:
740
ADDRESS:1100 E SPRUCE AVETELEPHONE:
(559) 449-8070
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:88CENSUS: DATE:
11/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Resident Services Director, Kimberly EldridgeTIME COMPLETED:
01:00 PM
NARRATIVE
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On 11/16/2020, Licensing Program Analyst (LPA) A. Walton contacted the above facility via telephone due to COVID-19 and pre-cautionary measures. LPA introduced self and requested to speak with Resident Services Director (RSD), Kimberly Eldridge. LPA discussed the purpose of the call with RSD.

The purpose of today's case management visit, is to follow up on an incident that occurred on 11/3/2020 when S1 gave medication belonging to R2 to R1. This caused R1 to receive an additional dose of medication. S1 misread the number placed on the medication cup. S1 notified R1's responsible party and the physician. Physician instructed staff to hold R1's medication for 1 day and continue to monitor R1. S1 "was pulled off the floor" and given additional training that included shadowing another Medication Care Staff..

Based on today's visit, a deficiency is being cited in the area evaluated and listed on the 809-D according to California Code of Regulations Title 22, Division 6.

An exit interview was conducted and a Plan of Correction was reviewed and developed with the RSD. A copy of this report and appeal rights were discussed and provided to RSD, Kimberly Eldridge, via email and an electronic read receipt confirms receiving these documents. Facility representative signature on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: WINDHAM, THE
FACILITY NUMBER: 107208930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2020
Section Cited

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87465 Incidental Medical and Dental Care(a)(5): The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Based on interviews, R1 received medication meant for another residents causing R1 to receive a double dose of medication. This poses an immediate health and safety risk to persons in care.
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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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2020
LIC809 (FAS) - (06/04)
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