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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 11:02:32 AM

Substantiated


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
03/12/2024 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240312135821
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:
10:22 AM
MET WITH:Administratot Aurelien FruitTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Residents not accorded dignity
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 03/15/2024, 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 #2 -Residents #14.LPA obtained copies of the following documents: staff roster, resident roster, R1’and R2’s physicians report (LIC 602), face sheet, admission agreement, and employees 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: 1 of 3
Control Number 18-AS-20240312135821
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 “Residents not accorded dignity”, It is alleged that S1 took a video of R1 and R2 having intercourse without permission or consent and shared it with staff. During interviews with Administrator, it was revealed that there was a recording by S1 and several staff did see it. A full-blown investigation was conducted by the corporate office and S1 was terminated and staff that saw and did not report video were given a final write up. During interviews with staff three (3) out of three (3) interviewed denied ever seeing a video and stated they have never recorded residents nor heard of staff doing so. During interviews with residents thirteen (13) out of fourteen (14) stated to their knowledge staff has never recorded or taken a picture of them without their permission.

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: 2 of 3
Control Number 18-AS-20240312135821
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)(1)(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:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
(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 and R2 were video recorded by S1 having intercourse without their knowledge or consent.
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: 3 of 3