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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208930
Report Date: 06/21/2021
Date Signed: 06/21/2021 03:46:36 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210211085853
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:
06/21/2021
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Administrator, Kelly MetzTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Residents do not get an appropriate variety of foods
Residents are served food that is not properly cooked
INVESTIGATION FINDINGS:
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On 06/21/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced at the above facility to deliver findings on the above allegations. LPA introduced self and requested to speak with the Administrator (ADM). LPA met with Administrator, Kelly Metz. LPA explained the purpose of the visit to ADM.

During the course of the investigation, LPA conducted staff and resident interviews, conducted a facility tour, and reviewed records.

Consistent statements from residents concluded that the facility kitchen will serve a protein, such as chicken or pork, with gravy or "some kind of sauce". Additionally, interviews with residents revealed that there is not a variety of foods offered to residents and meals are "cold". Records review revealed that temperature ranges for food were "not within range on several days.

CONTINUED TO LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20210211085853
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/21/2021
NARRATIVE
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Based on record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the allegations: Residents do not get an appropriate variety of foods and Residents are served food that is not properly cooked are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, see LIC9099D.

An exit interview was conducted. A Plan of Correction was developed and reviewed with Administrator. A copy of this report and Appeal Rights were discussed and will be provided to Administrator via email, due to COVID-19 precautionary measures. An electronic read receipt will confirm receiving these documents. Administrator was informed to select yes when prompted. 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: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 24-AS-20210211085853
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2021
Section Cited
CCR
87555(b)(5)
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87555 General Food Service Requirements (b)(5): Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement was not met as evidenced by:
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Licensee agreed to submit documentation detailing how the requirements of General Food Service will be met by 07/21/2021. Licensee stated staff will receive training. Evidence of the training will be submitted by 07/21/2021.
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Based on interviews, Licensee did not ensure residents received an appropriate variety of foods, which poses a potential health and safety risk to persons in care.
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Licensee stated that the facility will send the "always available menu" to residents and a reminder that a "suggestion box" is available. Licensee will implement a substitution log to document what foods are available when main dishes run out.
Type B
07/21/2021
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (a): The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by:
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Licensee agreed to submit documentation detailing how the requirements of General Food Service will be met by 07/21/2021.
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Based on interveiws and records review, Licensee did not ensure that all food was prepared and served in a safe manner, when the temperature of meals where out of range on several days, which poses a potential health and safety risk to persons in care.
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Licensee stated that the facility will audit the temperature logs weekly to ensure meal temperatures are in range and are being documented on the temperature logs.
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: 06/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210211085853

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:
06/21/2021
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Administrator, Kelly MetzTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility does not have enough food for residents in care
INVESTIGATION FINDINGS:
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On 06/21/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced at the above facility to deliver findings on the above allegation. LPA introduced self and requested to speak with the Administrator (ADM). LPA met with Administrator, Kelly Metz. LPA explained the purpose of the visit to ADM.

During the course of the investigation, LPA conducted staff and resident interviews, conducted a facility tour, and reviewed records.

Based on interviews conducted with staff and residents, the allegation: Facility does not have enought food for residents in care is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies issued. An exit interview was conducted with Administrator. Due to COVID-19 precautionary measures, a copy of this report was provided via email and an electronic signature confirms receiving this document. Facility Representative signature on file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 1