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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602798
Report Date: 05/16/2025
Date Signed: 05/16/2025 04:23:23 PM

Document Has Been Signed on 05/16/2025 04:23 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WINDSOR HALL CARE HOME INC.FACILITY NUMBER:
197602798
ADMINISTRATOR/
DIRECTOR:		HONEYLET URREAFACILITY TYPE:
735
ADDRESS:1415 W. JAMES WOODTELEPHONE:
(213) 383-1547
CITY:LOS ANGELESSTATE: CAZIP CODE:
90015
CAPACITY: 82CENSUS: 77DATE:
05/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Honeylet Urrea, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analysts (LPAs) Daniel Konishi and Gabriela Castro made an unannounced annual inspection visit. LPA met with Administrator Honeylet Urrea and explained the purpose of today's visit.

This is a four-story adult residential facility (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 is 77.

The following 10 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant & Environment Safety, Operational Requirements, Staffing, Client Rights-Information, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention.

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. LPAs observed 8 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WINDSOR HALL CARE HOME INC.
FACILITY NUMBER: 197602798
VISIT DATE: 05/16/2025
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Physical Plant & Environment Safety [Cont.]: 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 nine (9) clients’ bedroom/bathrooms that LPAs observed and temperature measured between 106.5-114.6 degrees F which is within the required range of 105-120 degrees F. Facility has replaced water boiler with 4 tankless water heaters. 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 04/25/25. Carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed on each floor/level and are fully charged.

Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/disaster drill on 04/25/25.

Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.

Client Rights-Information: Facility provides telephone landline and internet for the clients. No Clients have postural supports.

Food Service: The kitchen is kept clean. LPAs observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The facility has sufficient food supply for two days perishable and seven days non- perishable. All the food in the facility are stored properly. Currently, there's no client in the facility required modified diet.

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, LPAs reviewed random selection of 8 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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WINDSOR HALL CARE HOME INC.
FACILITY NUMBER: 197602798
VISIT DATE: 05/16/2025
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Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Due to time restraint and LPAs were not able to complete the full inspection tool and interview residents and staff and LPAs will come back at another time to complete.



Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit Interview conducted and a copy of the report was provided to the Administrator Honeylet Urrea.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC809 (FAS) - (06/04)
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