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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602798
Report Date: 04/07/2022
Date Signed: 04/07/2022 02:13:36 PM

Unsubstantiated


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
03/30/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220330163541
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: 74DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:S-1 and S-2/Facility AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff prevented a resident from receiving Social Security benefits.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial complaint visit to investigate the above allegation. LPA met with S-1 and S-2 and discussed the purpose of today's visit.

During today's visit, LPA obtained the Client Roster, Staff Roster, reviewed Client #1's (C-1) file and obtained relevant documentation. LPA also interviewed Staff #1 (S-1), Staff #2 (S-2), C-1 and Placement Agency Social Worker.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20220330163541
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 HALL CARE HOME INC.
FACILITY NUMBER: 197602798
VISIT DATE: 04/07/2022
NARRATIVE
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Allegation: Staff prevented a resident from receiving Social Security benefits. During this investigation, LPA interviewed Staff #1 (S-1), Staff #2 (S-2), C-1 and Placement Agency Social Worker. LPA also reviewed C-1's file and obtained relevant documentation. Staff interviews and interview with Placement Agency Social Worker revealed that C-1 underwent a telephone interview with the Social Security Office approximately in October 2021 and due to this telephone interview, C-1 was determined not to be eligible for Social Security Benefits and was requested to re-pay the benefits paid to C-1 from the time C-1 was 18 years of age until October 2021. The Placement Agency Social Worker indicated that an appeal has been filed and continues to be pending and "it may take a minimum of 6 months" for a response. The Placement Agency Social Worker also indicated that C-1's placement costs will continue to be paid by the Placement Agency. C-1 was also interviewed and C-1 provided the same information that was provided by interviewed staff and the placement agency social worker. Interviews also revealed that C-1 is unconserved and C-1 nor any of C-1's family member have expressed the desire to participate in C-1's program plan. 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 was conducted, a copy of this report and Appeal Rights were provided to S-2/Facility Administrator.


NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2