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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602798
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:48:56 PM

Document Has Been Signed on 06/22/2023 02:48 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
GREATER LA AC/SC, 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: 75DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Honeylet UrreaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst ( LPA) Tena Herrera made an unannounced annual inspection visit. LPA met with Administrator Honeylet Urrea who was accompanied by Program Director Maria Lim and explained the purpose of today's visit.
This is a four-story adult residential faciilty (ARF) facility consisting of 48 client bedrooms with personal restroom in each room, lobby, office, kitchen, dining room, activities room, common room, laundry room, storage room, medication room and outdoor shaded activity area. This facility is licensed at a capacity of 82 clients and today's census was 75.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.


Physical Plant & Environment Safety: There are 48 client bedrooms with personal bathroom in each room, lobby, office, kitchen, dining room, activities room, common room, laundry room, storage room, medication room and outdoor shaded activity area. LPA observed 12 client bedrooms/bathrooms and closet/drawer space to accommodate each client comfortably was available. The facility is free of debris/hazards and the outdoor passageways and activity area are free of obstruction. No bodies of water were observed at the facility.There are no security bars or weapons on the premises. The hot water temperature was tested in the 12 client bedroom/bathrooms that LPA observed and temperature measured between 115.1 – 126.8 degrees F which is beyond the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured closet and inaccessible to clients. The last Fire/Emergency Drill was conducted on 05/26/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed on each floor/level and are fully charged.

(continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 02:48 PM - It Cannot Be Edited


Created By: Tena Herrera On 06/22/2023 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WINDSOR HALL CARE HOME INC.
FACILITY NUMBER: 197602798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 5 out of the 12 client bathrooms where water temperature was tested were oberved to be higher than the requrired range of 105-120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2023
Plan of Correction
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Administrator will adjust water heater accordingly and create a water log starting 06/23/2023 and record water temperature readings 3 time daily (morning, afternoon, and evening) for the next 5 calendar days, ending on 06/27/2023. Administrator will send proof of water temperature log to LPA via emai by the Plan of Correction (POC) due date of 6/28/23. with the first record of water log on 06/23/23 and subsequent recorded readings must measure within 105 -120 degress F.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WINDSOR HALL CARE HOME INC.
FACILITY NUMBER: 197602798
VISIT DATE: 06/22/2023
NARRATIVE
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Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Honeylet Urrea certificate expires on 10/11/23.
Personnel Records-Training: Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility located in a locked cabinet in the living room. Staff have current CPR/first aid training and sufficient on-going training.
Client Rights-Information: Client personal rights poster is posted in the facility.
Client Records-Incident Reports: Client files are kept in a secure location within the facility office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked medication cart located in the medication room. All medications in properly labeled and in their original containers. During the visit today, LPA reviewed all 7 clients' medications, and no issues were observed.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 5 Client interviews and 5 Staff interviews during todays visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were cited on the attached 809D.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Honeylet Urrea.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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