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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208930
Report Date: 03/30/2021
Date Signed: 03/30/2021 02:44:44 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:
03/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator, Kelly MetzTIME COMPLETED:
02:55 PM
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On 3/30/2021, Licensing Program Analyst (LPA) contacted Administrator, Kelly Metz to conduct a Case Management visit via telephone due to COVID-19 and precautionary measures. The purpose of today’s visit it to follow up on an incident report that was submitted to the Fresno CCL office.

It was reported that on 3/17/2021, S1 was in route to administer medication to R2, when S1 was stopped by R1. During the conversation between S1 and R1, S1 gave medication meant for R2 to R1. S1 immediately notified Resident Care Supervisor. R1’s Responsible Party and Primary Care Physician notified.

On 11/16/2020, LPA conducted a Case Management visit at the above facility. LPA issued a citation based on California Code of Regulations Section 87465(a)(5).

Based on today’s visit, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached 809D. A Civil Penalty is being assessed in the amount of $250 for Repeat Violation in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Kelly Metz, 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: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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: 03/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/01/2021
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, S1 administered medication meant for R2 to R1 causing R1 to recevie the wrong 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: 03/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2021
LIC809 (FAS) - (06/04)
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