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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403366
Report Date: 06/28/2021
Date Signed: 06/28/2021 11:23:15 AM



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
05/27/2020 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200527162335
FACILITY NAME:WINDSOR COURT ASSISTED LIVINGFACILITY NUMBER:
336403366
ADMINISTRATOR:BRITTANY HOLMFACILITY TYPE:
740
ADDRESS:201 S. SUNRISE WAYTELEPHONE:
(760) 327-8351
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:130CENSUS: 111DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Patrick McAdoo-MortonTIME COMPLETED:
10:37 AM
ALLEGATION(S):
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9
Facility staff is not adhering to the terms and conditions of the admission agreement.
Facility staff did not inform resident's responsible party of fee increase in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natalie Gayoso conducted a complaint visit to deliver findings regarding the above allegations. LPA identified herself and discussed the purpose of the visit and the elements of the above allegations with Patrick McAdoo-Morton

The investigation consisted of interviews with relevant parties and records review. The first allegation indicates facility staff is not adhering to the terms and conditions of the admission agreement. Interview with Staff 1 (S1) revealed the prior administrator had given Resident 1 (R1) family a new temporary monthly rate of $2800 which included total care while R1’s family looked for a new facility to place R1. The care that was included consisted of incontinent care, medication management, and bathing. Per administrator these services are an additional cost. LPA reviewed admissions agreement and observed it to be incomplete. It did not list the monthly rate nor rate for additional services being provided. Facility was unable to provide a signed agreement regarding temporary monthly rate.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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
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
05/27/2020 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200527162335

FACILITY NAME:WINDSOR COURT ASSISTED LIVINGFACILITY NUMBER:
336403366
ADMINISTRATOR:BRITTANY HOLMFACILITY TYPE:
740
ADDRESS:201 S. SUNRISE WAYTELEPHONE:
(760) 327-8351
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:130CENSUS: 111DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Patrick McAdoo-MortonTIME COMPLETED:
10:37 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure that the resident's room was cleaned.
facility staff is not providing adequate food service.
INVESTIGATION FINDINGS:
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2
3
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5
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7
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13
Licensing Program Analyst (LPA) Natalie Gayoso conducted a complaint visit to deliver findings regarding the above allegations. LPA identified herself and discussed the purpose of the visit and the elements of the above allegations with Administrator Patrick McAdoo-Morton.

The investigation consisted of interviews with relevant parties. The first allegation indicates facility staff did not ensure that the resident's room was cleaned. Interview with S1 stated they never claims/complaints were made to staff or management by R1’s facility that the room was not clean. Only once did R1’s family state a dish found in the closet. Interview with S2 stated R1’s room was always clean, organized and did not contain odors

The second allegation indicated facility staff is not providing adequate food service. S1 stated the facility had a fire in the kitchen and temporarily the facility had to serve an alternate menu that was being provided while kitchen was being repaired. The facility also had a list of residents with dietary restrictions and had additional options for those individuals. LPA verified that a Special Incident Report was provided to the Department
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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-20200527162335
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: 06/28/2021
NARRATIVE
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and included menu of meals served while kitchen was being repaired.

Based on the information obtained, the allegations are UNSUBSTANTIATED. A finding of Unsubstantiated means that 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.

An exit interview was conducted and a copy of this report, LIC 9099D, and Appeal Rights were provided to Administrator
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200527162335
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: 06/28/2021
NARRATIVE
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The second allegation facility staff did not inform resident's responsible party of fee increase in a timely manner. Interview with S1 revealed the facility had failed to notify R1’s family 60 days prior to fee increase starting the month of May 2020. LPA reviewed transaction report and observed the facility had charge additional fees starting May 2020 but were later reversed.

Based on LPA records review and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 & Chapter 6, are being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200527162335
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: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2021
Section Cited
CCR
87507(f)
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Admission Agreements: The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
This requirement was not met as evidenced by:
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The administrator has agreed to review California Code of Regulation 87507 Admission Agreement and send a memorandum of understanding to CCL by POC date.
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Based on records review the facility failed to comply with admissions agreement and could not provide proof of signed agreement for temporary rate. This poses a potential risk to residents in care.
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Type B
07/02/2021
Section Cited
HSC
1569.655(a)
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Increase in fee rates for elderly residents...: (a)If a licensee of a residential care facility for the elderly increases the rates... the licensee shall provide no less than 60 days' prior written notice to the residents...
This requirement was not bet as evidenced by:
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The administrator has agreed to review Health and Safety Code 1569.655 and send a memorandum of understanding to CCL by POC date.
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Based on interview with administrator, the facility failed to provide a 60 notice prior to rate increase being charged. This poses a potential risk to residents 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.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5