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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191202190
Report Date: 02/25/2022
Date Signed: 02/25/2022 02:27:54 PM


Document Has Been Signed on 02/25/2022 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:WINDSORFACILITY NUMBER:
191202190
ADMINISTRATOR:CAMERON, LEIF JFACILITY TYPE:
741
ADDRESS:1230 EAST WINDSOR ROADTELEPHONE:
(818) 244-7219
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:175CENSUS: 26DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Natlicole Kincherlow, Director of Wellness
TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the infection control domain. LPA Chan met with the Director of Wellness, Natlicole Kincherlow, and explained the purpose of the visit. The facility is licensed as a Continuing Care Residential Community (CCRC) to serve 175 residents of which 70 may be non-ambulatory and 5 may be bedridden. There is a hospice waiver for 5 residents. The facility currently has 26 residents in Assisted Living, 54 in Independent Living, and 14 in Skilled Nursing.

The community includes an Assisted Living, Independent Living, and Skilled Nursing area. LPA Chan toured the one story Assisted Living side that consists of 39 resident rooms, 2 spacious outdoor areas with ample tables and chairs, a large activity/lounge room, a dining room, and additional eating area.
Upon entry, the facility has a check-in station for covid-19 questionnaire and taking visitors/staff temperature. Covid-19 signage such as social distancing and symptoms are posted around the facility. LPA recommended staff to add more signage such as cough/sneeze etiquette and hand washing in the common areas and in the kitchen. LPA inspected 4 rooms: #26, #31, #35, and #46 and the hot water temperature in those rooms measured within the required range of 105 - 120 degrees Fahrenheit. The residents' rooms have the adequate furniture for comfort living. The smoke detectors and carbon monoxide detectors were tested and functional. The refrigerators and freezers are set at appropriate temperatures. There was sufficient perishable and non-perishable food and items are properly stored. The hallways and stairways are clear and free of any obstructions.
LPA selected 4 resident files to confirm emergency contact is updated and to check their medications. LPA observed discrepancies for all 4 resident's medication where medications are not being administered as ordered by the physician.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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Document Has Been Signed on 02/25/2022 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: WINDSOR
FACILITY NUMBER: 191202190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2) (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and LPA observation, the licensee did not comply with the above regulation for 4 out of 4 residents' medications to ensure they are being administered as prescribed by the physician which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2022
Plan of Correction
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The Administrator will review residents' medications to ensure they are being given up to date and conduct an in-service training to medication staff. The in-service training log will be submitted to LPA by POC due date of 2/26/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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