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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 03:42:22 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
08/20/2020 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20200820093446
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:
11:58 AM
MET WITH:Administrator, Kelly MetzTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Staff are mismanaging resident's medications
Staff steal resident's food
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.

Interviews with staff revealed that on 05/08/2020, it was found that a narcotic had been replaced with a Tylenol. The incident was noted on the narcotic log. This incident was not reported to the Fresno CCL office.

Continued to 9099C
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 5
Control Number 24-AS-20200820093446
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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Interviews with staff revealed that a staff member was found in a facility bathroom eating desserts and snacks from a meal cart. The desserts and snacks were ordered for residents but consumed by the staff member. Per Administrator, the staff member received disciplinary action.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the allegations: Staff are mismanaging resident’s medications and staff steal resident’s food 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 Right 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: 2 of 5
Control Number 24-AS-20200820093446
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)(3)
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87555 General Food Service Requriements: (3) Between-meal nourishment or snacks shall be made available for all 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 Requirements will be met by 07/21/2021.
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Based on interviews. Licensee did not ensure snacks were made available to residents in care when a staff member was found eating snacks belonging to residents in the facility bathroom, which poses a potential health and safety risk to persons in care.
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Type B
07/21/2021
Section Cited
CCR
87465(h)(5)
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87465 Incidental Medical and Dental Care:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
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Licensee stated that staff have received training on the requirements of Incidental Medical and Dental Care. Evidence of the training will be submitted to CCLD by 07/21/2021.
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Based on interviews: Licensee did not ensure medications are stored in it's original container, when a tylenol was found in place of a narcotic, which poses a potential health and safety risk to residents in care.
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Licensee will conduct medication training each month regarding Incidental Medical and Dental Care regulations.
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: 3 of 5
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
08/20/2020 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20200820093446

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:
11:58 AM
MET WITH:Administrator, Kelly MetzTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Staff handled resident in a rough manner causing injury
Staff yell at residents
Staff did not safeguard resident's person items
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, stated the purpose of the visit, and requested to speak with the Administrator (ADM). LPA met with Administrator, Kelly Metz.

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

Interviews with staff revealed that S1 can be “stern” with resident’s which can “rub people the wrong way”. S1 is does not handle residents in a rough manner and does not yell at residents.

When a resident is away from the apartment, the apartment door is locked. Staff do not have access to the apartment. Facility staff will open the apartment door if requested by the residents’ responsible party.
CONTINUED TO LIC9099C
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: 4 of 5
Control Number 24-AS-20200820093446
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 interviews conducted with staff and residents, the allegations: Staff handled resident in a rough manner causing injury, staff yell at residents and staff did not safeguard resident’s personal items are 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.

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: 5 of 5