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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208930
Report Date: 12/20/2021
Date Signed: 12/20/2021 01:40:05 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: 69DATE:
12/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Administrator, Kelly Metz and Resident Services Director, Barbara RobinsonTIME COMPLETED:
01:43 PM
NARRATIVE
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On 12/20/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced at the above facility to conduct a Case Management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Kelly Metz and Resident Services Director, Barbara Robinson

The purpose of today’s visit is to follow up on an incident report that was submitted to the Fresno CCL office on 11/30/2021.

It was reported that on 11/20/2021 at approximately 8:00PM, R1 was given the wrong dose of Oxycodone. Physician order indicates that R1 should receive one 5mg tablet of Oxycodone by mouth at bed time. On the date indicated above, R1 was given two 5mg tablets equaling 10mg. Facility staff notified physician and responsible party.

On 03/30/2021 and 05/07/2021, LPA Walton conducted Case Management visits to follow up on reports that facility did not administer medication as prescribed. The facility was issued a citation on both dates based on California Code of Regulations Section 87465(a)(5).

Based on interviews and record review, a deficiency is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(a)(5) on the attached 809D. A Civil Penalty is being assessed in the amount of $1,000 for a repeat violation in accordance with California Code of Regulations, Title 22.

An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. As a COVID-19 precautionary measure, a copy of this report and appeal rights were provided via email and an electronic read receipt confirms receiving these documents. Report signed on-site by facility representative.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
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: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2021
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 and record review, Facility staff administered two 5mg tablets of Oxycodone to R1 instead of the ordered 5mg. 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: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2021
LIC809 (FAS) - (06/04)
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