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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403366
Report Date: 08/23/2022
Date Signed: 08/23/2022 12:53:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220818172214
FACILITY NAME:WINDSOR COURT ASSISTED LIVINGFACILITY NUMBER:
336403366
ADMINISTRATOR:PATRICK MCADOO MORTONFACILITY TYPE:
740
ADDRESS:201 S. SUNRISE WAYTELEPHONE:
(760) 327-8351
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:130CENSUS: 128DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Bobbie Rodriguez - Memory Care DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not prevent resident from wandering away from the facility
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Memory Care Director Bobbie Rodgriguez and informed her of the purpose of today's inspection. Below is a summary of the findings of the investigation:

Regarding allegation “Staff did not prevent resident from wandering away from the facility”: LPA Colvin interviewed staff and witnesses related to the event as well as reviewed the facility’s file for prior resident (R1). LPA Colvin confirmed that on 4/4/22, R1 eloped from the facility without staff knowledge by unfastening a screw from their window and then scaling a low wall. While the facility’s Special Incident Report (SIR) to Licensing states that staff became aware of the elopement within 45 minutes of R1’s departure from the facility, the facility’s internal report shows that staff noted the absence at 2:54pm and last observed R1 in the facility at 12:16pm. Prior to entering the facility, R1 had a well-documented history of elopement and exit seeking, and had been required to be in a locked residence due to this behavior.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
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 8
Control Number 18-AS-20220818172214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WINDSOR COURT ASSISTED LIVING
FACILITY NUMBER: 336403366
VISIT DATE: 08/23/2022
NARRATIVE
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Therefore, based on record review, the allegation “Staff did not prevent resident from wandering away from the facility” is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Memory Care Director Bobbie Rodgriguez during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 18-AS-20220818172214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WINDSOR COURT ASSISTED LIVING
FACILITY NUMBER: 336403366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2022
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed ...residents in...facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by:
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Licensee agrees to re-evaluate how frequently residents with exit-seeking behavior should be checked on by staff. Licensee to additionall review how R1 exited from the facility and consider implementing additional precautions to the faciltiy's physical plant. Licensee to provide LPA Colvin with Self-Certification of inspection
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Based on interview and record review, the licensee did not comply with the above regulation with one resident (R1). On 4/4/22, R1 was able to exit the facility without staff's knowledge. Staff did not check on R1 from 12:16pm to 2:54pm. R1 was a known exit-seeker. This was an immedaite safety risk R1.
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of physical plant and where R1 escaped from, and inform LPA Colvin if any changes are going to be made to prevent furture elopements. Licensee to additionally inform LPA Colvin if they have concluded if residents with elopement behavior require additional status checks. Due by Plan of Correction date of 8/24
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220818172214

FACILITY NAME:WINDSOR COURT ASSISTED LIVINGFACILITY NUMBER:
336403366
ADMINISTRATOR:PATRICK MCADOO MORTONFACILITY TYPE:
740
ADDRESS:201 S. SUNRISE WAYTELEPHONE:
(760) 327-8351
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:130CENSUS: 128DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Bobbie Rodgriguez - Memory Care DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not prevent resident from engaging in inappropriate behaviors
Staff refused to provide resident representative with medical records
Staff are not following resident's physician orders
Facility did not notify resident's authorized representative of incidents
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Memory Care Director Bobbie Rodgriguez and informed her of the purpose of today's inspection. Below is a summary of the findings of the investigation:

Regarding allegation “Staff did not prevent resident from engaging in inappropriate behaviors”: LPA Colvin reviewed facility records for resident (R1) and interviewed witnessed with knowledge of incidents involving R1. LPA Colvin confirmed that during R1’s time at the facility, R1 exhibited several behaviors, such as pulling out their own hair and taking personal phones from other people. According to staff interviews, R1 did not have a history of these behaviors prior to entering the facility. Additionally, once staff addressed these behaviors with R1, they were not repeated while R1 was in the facility. Since R1 did not have a documented history of these behaviors, the facility did not have a plan in place to supervise the resident for these specific behaviors.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 18-AS-20220818172214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WINDSOR COURT ASSISTED LIVING
FACILITY NUMBER: 336403366
VISIT DATE: 08/23/2022
NARRATIVE
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Therefore, based on record review and interviews conducted, the allegation “Staff did not prevent resident from engaging in inappropriate behaviors” is UNSUBSTANTIATED.

Regarding allegation “Staff refused to provide resident representative with medical records”: LPA Colvin interviewed relevant witnesses regarding R1’s Power of Attorney’s (POA) request for all of R1’s records from the facility. Interviews conducted by LPA Colvin reveal conflicting dates on when the records were requested, ranging from the day prior to R1 moving out of the facility to a week prior to R1 moving out of the facility. In LPA Colvin’s interview with Administrator Patrick Mackadoo-Morton, the Administrator stated that the reason the records could not be provided the same day the POA requested was due several factors, such as: the Administrator not being present, it being after business hours on a Friday, and that the POA was requesting records which may have other residents listed in them as well (such as internal incident reports), which the Administrator would have to redact for other resident’s privacy. Title 22 Regulations section 87468.2(a)(19) requires that facilities to produce resident records for the resident or representatives within two business days. Since LPA Colvin is unable to confirm which date R1’s POA requested the records, and one of the dates provided via interview falls within the allotted two business days, the allegation “Staff refused to provide resident representative with medical records” is UNSUBSTANTIATED.

Regarding allegation “Staff are not following resident's physician orders”: LPA Colvin conducted interviews and reviewed relevant documents from R1’s facility file regarding medications prescribed to R1 as well as dates administered, and dates refused. LPA Colvin confirmed through interviews that R1 requested information on R1’s medications, such as side effects, and after staff provided this information to R1, R1 refused to take some of their medication. Facility staff communicated with R1’s POA and R1’s physician regarding R1’s concerns about the medication and subsequent refusals. Facility staff continued to offer R1 all prescribed medications at directed administration intervals, but R1 continued to refuse certain medications. Residents retain the right to refuse medications and staff are not permitted per Title 22 Regulations to force medications or camouflage them in any substance. Therefore, due to record review and interviews conducted, the allegation “Staff are not following resident's physician orders” is UNSUBSTANTIATED.

Regarding allegation “Facility did not notify resident's authorized representative of incidents”: LPA Colvin reviewed pertinent documents from R1’s facility file as well as interviewed facility staff regarding specific incidents of concern with R1 and how information was communicated to R1’s POA.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 18-AS-20220818172214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WINDSOR COURT ASSISTED LIVING
FACILITY NUMBER: 336403366
VISIT DATE: 08/23/2022
NARRATIVE
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LPA Colvin confirmed that regarding R1’s pulling out of their hair that while staff had previously seen some hair in R1’s trash can on 8/4/22, there was not a concern regarding R1 pulling out their hair until 8/12/22. . Staff interviews are consistent in that this was not observed until the evening (approximately 7:30pm) on 8/12/22, and at that time R1 was being visited by their POA, so the information was relayed to POA in person verbally. Notes in R1’s file support these statements, and interviews reflect that R1 did not have prior behavior of pulling out their hair. Other reportable incidents observed by LPA Colvin in R1’s file include R1’s medication refusal and an elopement from the facility on 4/4/22. Both items were also reported to R1’s POA, which is supported by documentation and interviews. Therefore, based on interview and record review, the allegation “Facility did not notify resident's authorized representative of incidents” is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Memory Care Director Bobbie Rodgriguez and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220818172214

FACILITY NAME:WINDSOR COURT ASSISTED LIVINGFACILITY NUMBER:
336403366
ADMINISTRATOR:PATRICK MCADOO MORTONFACILITY TYPE:
740
ADDRESS:201 S. SUNRISE WAYTELEPHONE:
(760) 327-8351
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:130CENSUS: 128DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Bobbie Rodgriguez - Memory Care DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff took resident's phone away
Facility denied resident from having visitors
Resident is not allowed to participate in activities
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Memory Care Director Bobbie Rodgriguez and informed her of the purpose of today's inspection. Below is a summary of the findings of the investigation:

Regarding allegation “Staff took resident's phone away”: LPA Colvin conducted interviews and reviewed records in resident’s (R1) facility file regarding R1’s use of telephones as well as R1’s Power of Attorney removing R1’s phone from the facility due to R1’s continued phone calls which disrupted R1’s care and/or finances. All interviews conducted confirm that the phone was taken away from R1 by the POA, and not by the facility. Therefore, based on interviews and record review, the allegation “Staff took resident's phone away” is UNFOUNDED.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 18-AS-20220818172214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WINDSOR COURT ASSISTED LIVING
FACILITY NUMBER: 336403366
VISIT DATE: 08/23/2022
NARRATIVE
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Regarding allegation “Facility denied resident from having visitors”: LPA Colvin conducted interviews with persons related to the allegation and all parties agree that R1 was never denied from having visitors, though after an incident between the Administrator and R1’s POA, the Administrator did state that they would institute modifications to R1’s POA visiting them, due to the Administrator’s concern for R1’s safety. Since R1 was never denied any visitors and R1 was moved from the facility prior to this new modification being implemented in any future visitation, the allegation “Facility denied resident from having visitors” is UNFOUNDED

Regarding allegation “Resident is not allowed to participate in activities”: LPA Colvin interviewed persons related to the allegation as well as reviewed staff notes for R1’s facility file. LPA Colvin observed a staff note in which it was documented that R1’s POA was requesting for R1 to attend some events in the Assisted Living portion of the facility. The note reflects that staff informed the POA that R1 was welcome to attend the events, but that the POA would need to accompany R1. R1 was a resident in the Memory Care unit of the facility, which is locked, and therefore it is practical that R1 would need supervision to be in the Assisted Living portion of the facility, which is not locked. Additional interviews suggest that R1 was not prohibited from attending other activities, which are offered to Memory Care residents. Therefore, based on interviews conducted and record reviewed, the allegation “Resident is not allowed to participate in activities” is UNFOUNDED.

We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Memory Care Director Bobbie Rodgriguez and report provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8