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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208930
Report Date: 05/07/2021
Date Signed: 05/07/2021 11:33:42 AM

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: 71DATE:
05/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Executive Director, Kelly Metz and Resident Services Director, Kimberly ElderidgeTIME COMPLETED:
11:40 AM
NARRATIVE
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On 05/07/2021, Licensing Program Analyst (LPA) A. Walton conducted a Case Management-Incident visit via telephone due to COVID-19 and precautionary measures. LPA introduced self and requested to speak with Administrator. LPA met with Executive Director (ED), Kelly Metz and Resident Services Director (RSD), Kimberly Elderidge.

The purpose of today's visit is to follow up on an Incident Report submitted to the Fresno CCL office on 04/23/2021.

It was reported that on 04/18/2021 at approximately 8:00PM, S1 administered 10mg of Zolpidem to R1. R1's order states "Zolpidem 10mg", however, the description states to take 0.5 Tab by mouth". R1 received one 10mg tablet instead of the ordered 5mg/0.5 tablet.

On 11/16/2020 and on 03/30/2021, LPA conducted a Case Management visit at the above facility. The facility was issued a citation on both dates 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 $1000 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: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
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: 05/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2021
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 10mg of Zolpidem to R1 instead of the ordered 5mg. This poses an immediate health and safety risk to persons in care.
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POC Cleared during visit.

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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: 05/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2021
LIC809 (FAS) - (06/04)
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