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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191202190
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:25:44 PM


Document Has Been Signed on 03/01/2023 03:25 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,
, CA



FACILITY NAME:WINDSORFACILITY NUMBER:
191202190
ADMINISTRATOR:BEARCE, GREGORYFACILITY TYPE:
741
ADDRESS:1230 EAST WINDSOR ROADTELEPHONE:
(818) 244-7219
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:175CENSUS: 104DATE:
03/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:TIME COMPLETED:
03:30 PM
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On 03/01/2023 at 12:00 pm, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Agard conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. The facility is licensed as a Continuing Care Residential Community (CCRC) to serve 175 residents of which 70 may be non-ambulatory and five may be bedridden. There is a hospice waiver for five residents. The facility currently has 35 residents in Assisted Living, 69 in Independent Living, and 24 in Skilled Nursing.

The facility is located in a residential neighborhood. It is 4-stories in height with a lower level (LL). There is also a skilled nursing facility adjacent to the building. The facility has approximately 140 resident-bedrooms in total. Upon entry on the first floor, the concierge desk is directly to the right. Straight ahead is the main dining room/ lounge area and courtyard. The right hallway is the Assisted Living (AL) wing and the left hallway is the Independent Living (IL) wing. Residents bedrooms run throughout the facility on the 1st, 2nd, 3rd and 4th level. On the LL there is a laundry room, several activity rooms, a gym, movie cinema, beauty salon, private dining space and storage as well as some administrative offices. 1st floor contains several lounge/meeting areas, courtyard, dining, bistro, clinic for medications, kitchen, storage and library. The facility has a parking lot adjacent to the west wing of the building. The courtyard contains a covered patio.

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. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station near the facility entrance, dining room, and a visitor’s log. LPA observed required postings throughout the facility. Some rooms were inspected. Bed linen were sufficient in amount, adequate lighting was provided, storage for

cont on 9099C

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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,
, CA
FACILITY NAME: WINDSOR
FACILITY NUMBER: 191202190
VISIT DATE: 03/01/2023
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resident personal belongings was observed. Furnishings throughout the facility were observed to be in good condition. There are no security bars or weapons on the premises. Client bathrooms were checked, toilets and water faucets worked properly. The water temperature measured at 111.4 F. A comfortable temperature was maintained in the facility.

The telephone, which is a land line, was called by LPA and is operational. Emergency Disaster Plan and "See something, say something, Let Us Know" was observed posted in a foyer located in the AL wing. LPA observed several fully charged fire extinguishers throughout the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Dishes, cups and flatware were inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in the kitchen inaccessible to residents. Food supply was adequately stored in kitchen refrigerator and freezer.

Facility is equipped with dual smoke and carbon monoxide detectors. Which are hardwired and interconnected throughout the facility. Detectors are connected to notify the fire department in the event of a fire. Facility has a signal system that alerts facility staff of residents that may be in crisis. Appliances were observed in working order. There is a large refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.



No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC809 (FAS) - (06/04)
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