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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403366
Report Date: 06/29/2025
Date Signed: 06/29/2025 10:20:02 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
03/14/2024 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240314114727
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: 127DATE:
06/29/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Aurelien FruitTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Resident's motorized wheelchair broke due to staff neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 03/20/2025, LPA Banrasavong conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. On 06/28/2025 LPA Gutierrez interviewed Administrator, Staff #2- Staff #4, and Residents #1(Telephone) -Residents #13.LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians report (LIC 602), face sheet, and staff documents. During today’s visit LPA Gutierrez delivered findings.

See 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
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 5
Control Number 18-AS-20240314114727
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WINDSOR COURT ASSISTED LIVING
FACILITY NUMBER: 336403366
VISIT DATE: 06/29/2025
NARRATIVE
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In regard to the allegation “Resident's motorized wheelchair broke due to staff neglect”, It is alleged that S1 broke R1’s motorized wheelchair by turning it off and on. During interviews with Administrator, it was revealed that the wheelchair had never actually been broken and that the battery had just died. Three (3) out of three (3) staff all stated they have never witnessed staff break residents belongs. During interviews with residents’ thirteen (13) out of thirteen (13) stated that staff has never broken any of their belongs. R1 stated that S1 liked to turn their wheelchair off and on preventing it from working when the battery would die.

Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation(s). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

A copy of this report was given to the Administrator.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
03/14/2024 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240314114727

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: 127DATE:
06/29/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Aurelien FruitTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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9
Resident was abandoned due to staff neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 03/20/2025, LPA Banrasavong conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. On 06/28/2025 LPA Gutierrez interviewed Administrator, Staff #2- Staff #4, and Residents #1(Telephone) -Residents #13.LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians report (LIC 602), face sheet, and staff documents. During today’s visit LPA Gutierrez delivered findings.

See 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20240314114727
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WINDSOR COURT ASSISTED LIVING
FACILITY NUMBER: 336403366
VISIT DATE: 06/29/2025
NARRATIVE
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In regard to the allegation “Resident was abandoned due to staff neglect”, It is alleged that S1 left R1 in an inoperable motorized wheelchair unable to call for assistance. During interviews with Administrator, it was revealed that S1 left R1 knowingly in wheelchair not working unable to reach for call button or phone to ask for assistance. It was also revealed that S1 admitted to Administrator to leaving R1 alone because of the behavior issues R1 displays. During interviews with residents twelve (12) out of thirteen (13) stated they have never been neglected by staff. R1 stated that S1 knew the chair was not working and did not assist them to bed leaving him/her sitting waiting for another caregiver to find them.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Administrator. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20240314114727
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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: 06/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

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Administrator suspended then terminated S1 due to this behavior. Administrator agrees to conduct personal rights training for all current staff and send a list of material and a log of all employees who participated in training to LPA by POC due date.
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This deficiency is evidenced by the following:
R1 was left in a non-working motorized wheelchair in room unable to call for assistance by S1.
This poses a health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5