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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602798
Report Date: 06/14/2022
Date Signed: 06/14/2022 03:11:21 PM

Document Has Been Signed on 06/14/2022 03:11 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:WINDSOR HALL CARE HOME INC.FACILITY NUMBER:
197602798
ADMINISTRATOR:HONEYLETT URREAFACILITY TYPE:
735
ADDRESS:1415 W. JAMES WOODTELEPHONE:
(213) 383-1547
CITY:LOS ANGELESSTATE: CAZIP CODE:
90015
CAPACITY: 82CENSUS: 73DATE:
06/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Wellness Coordinator / Maria Lim
Assistant Administrator / Antonieta Dulay
Administrator / Honeylet Urrea		TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPA met with Wellness Coordinator / Maria Lim and Assistant Administrator / Antonieta Dulay and was later joined by the Administrator / Honeylet Urrea who assisted with the visit. LPA explained the purpose of today’s visit is to gather additional details surrounding the death of Client #1 (C1), which occurred on 6/5/22.

Based on interviews conducted and record reviews, LPA discovered that C1 was a client of Windsor Hall Care Home Inc for a short period. C1 was admitted to Windsor Hall Care Home Inc. on 5/3/22 and was hospitalized on 5/9/22 due to a psychiatric episode.

During today's visit, LPA interviewed the Administrator, Client 2 (C2 / former Roommate of C1) and Med Tech / Adan Morelia. Also, copies of the following documents were reviewed and obtained in reference to C1;

• Hospital Reports from Los Angeles Community Hospital @ Bellflower • Admission Agreement
• Preplacement Appraisal Information • Functional Capability Assessment • Unusual Incident/Injury Report
• Gateways Hospital Social Rehabilitation Program Full Assessment • Medication Administration Record
(MAR) for May 2022 • Nurses Notes

LPA requested the Administrator to obtain a copy of the Discontinue order (DC order) for medication Citalopram 20 MG for C1 and submit a copy to CCL by the end of business day on 6/15/22.

Due to time constraints, LPA had to terminate visit and will return on a later date to conclude the investigation.
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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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