191202190-12-8-2021-28-AS-MVAO-CCBRUY-20220308122044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191202190
Report Date: 12/08/2021
Date Signed: 12/08/2021 12:53:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/29/2020 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200929105647

FACILITY NAME:	WINDSOR		FACILITY NUMBER:	191202190
ADMINISTRATOR:	CAMERON, LEIF J		FACILITY TYPE:	741
ADDRESS:	1230 EAST WINDSOR ROAD		TELEPHONE:	(818) 244-7219
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	175	CENSUS: 87	DATE:	12/08/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility staff left resident on the floor for an extended period of time
Facility staffing is not sufficient to meet resident's needs

INVESTIGATION FINDINGS:

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On 10/07/2020, Licensing Program Analyst (LPA) Elizabeth Irra initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this was conducted telephonically with Yvette Duarte (Executive Director).
During this visit, LPA requested a copy of Staff Roster (including contact information), copy of Resident Roster including contact information, staff schedule for September 2020 and October 2020 and a list of Residents that are at Fall Risk and have a care plan in place.

During this investigation, reviewed relevant documentation and interviewed Staff #1 (S-1), Staff #3 (S-3), Staff #4 (S-4) and Staff #7 (S-7). LPA attempted to interview Staff #2 (S-2), Staff #5 (S-5) and Staff #6 (S-6) and was unable to do as they were not reachable. LPA also interviewed the Executive Director. LPA was unable to interview Resident #1 (R-1) and Resident #2 (R-2) as they are no longer residing at this facility. LPA interviewed Resident #3 through Resident #5 (R-3 through R-5). LPA attempted to interview Resident #6 through Resident #10 (R-6 through R-10) and was unable to do so as they were unable to comprehend the interview questions. Refer to LIC 9099C for the continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200929105647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/08/2021

NARRATIVE

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Allegation: Facility staff left resident on the floor for an extended period of time.
During this investigation, reviewed relevant documentation and interviewed Staff #1 (S-1), Staff #3 (S-3), Staff #4 (S-4) and Staff #7 (S-7). LPA attempted to interview Staff #2 (S-2), Staff #5 (S-5) and Staff #6 (S-6) and was unable to do as they were not reachable. LPA also interviewed the Executive Director. LPA was unable to interview Resident #1 (R-1) and Resident #2 (R-2) as they are no longer residing at this facility. LPA interviewed Resident #3 through Resident #5 (R-3 through R-5). LPA attempted to interview Resident #6 through Resident #10 (R-6 through R-10) and was unable to do so as they were unable to comprehend the interview questions. Staff interviews revealed that staff do not leave residents on the floor for an extended period of time. Interviewed staff indicated they have not received any concerns in regards to residents being left on the floor for an extended period of time. Interviewed staff indicated they have not called the Fire Department to assist a resident getting up from the floor (non-emergency service call). Interviewed staff indicated they carry a radio and a "beeper" during their shift. Per staff interviews, the facility signal system (when activated by residents) sends an alert to the nurses station and to the staff's "beeper" in which staff indicated they respond to in a timely manner. Resident interviews revealed that they have not been left on the floor for an extended period of time. Interviewed Residents indicated they are aware of the signal systems and how to use it. However, (2) out of (3) interviewed Residents indicated they have not had to use the signal system. (1) out of (3) interviewed Residents indicated they used the signal system and staff "came pretty promptly" to assist. Interviewed Residents indicated the Fire Department/Paramedics have not arrived to assist them for non-emergencies. Staff and Resident interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200929105647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/08/2021

NARRATIVE

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Allegation: Facility staffing is not sufficient to meet resident's needs.
During this investigation, reviewed relevant documentation and interviewed Staff #1 (S-1), Staff #3 (S-3), Staff #4 (S-4) and Staff #7 (S-7). LPA attempted to interview Staff #2 (S-2), Staff #5 (S-5) and Staff #6 (S-6) and was unable to do as they were not reachable. LPA also interviewed the Executive Director. LPA was unable to interview Resident #1 (R-1) and Resident #2 (R-2) as they are no longer residing at this facility. LPA interviewed Resident #3 through Resident #5 (R-3 through R-5). LPA attempted to interview Resident #6 through Resident #10 (R-6 through R-10) and was unable to do so as they were unable to comprehend the interview questions. Interviewed staff indicated staffing is sufficient to meet the resident's needs. Interviewed staff indicated they have not received any concerns in regards to staffing not being sufficient to meet the needs of the Residents. Interviewed Staff indicated that when a Resident falls, the nurse on shift assesses the Resident and determines the next step (such as calling 911 for emergencies). Per Staff interviews, the nurse assesses the Resident and if it is determined that the incident is not an emergency, the Nurse and the caregivers on shift assist with the transfers. Resident interviews revealed that staffing is sufficient to meet Resident needs. Interviewed Residents indicated that staff conduct rounds and assist them with their needs in a timely manner. Staff and Resident interviews do not corroborate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and Appeal Rights provided to the Executive Director.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC9099 (FAS) - (06/04)

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