336403366-11-20-2025-18-AS-RORN-DP7S2J-20251209122936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336403366
Report Date: 11/20/2025
Date Signed: 11/20/2025 11:03:57 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
12/12/2023 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20231212144731

FACILITY NAME:	WINDSOR COURT ASSISTED LIVING		FACILITY NUMBER:	336403366
ADMINISTRATOR:	PATRICK MCADOO MORTON		FACILITY TYPE:	740
ADDRESS:	201 S. SUNRISE WAY		TELEPHONE:	(760) 327-8351
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	130	CENSUS: 127	DATE:	11/20/2025
		UNANNOUNCED	TIME BEGAN:	08:06 AM
MET WITH:	Jillian Espinueva - Human Resources Payroll Staff		TIME COMPLETED:	11:18 AM

ALLEGATION(S):

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Staff did not assist resident in a timely manner.
Staff left resident unattended for a period of time.
Staff did not safeguard resident’s personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint regarding the above allegations. LPA met with Jillian Espinueva and explained the reason for the visit.

The investigation consisted of the following: On 12/18/23 LPA Banrasavong conducted an initial complaint investigation visit. On 1/21/25 LPA Banrasavong conducted a subsequent visit. On 11/7/25 LPA Flores contacted administrator and requested pertaining documents for resident #1(R1). On 11/10/25 LPA Flores interviewed R1's responsible party over the phone. On 11/12/25 LPA Flores interviewed 2 staff over the phone. On 11/18/25 LPA Flores interviewed 4 additional staff over the phone. On 11/20/25 LPA Flores interviewed 10 residents, conducted a tour of the facility, and delivered findings.

The investigation revealed the following: Regarding allegation: Staff did not assist resident in a timely manner. It is alleged resident used pulled cord to requested assistance and staff did not respond timely. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20231212144731

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: 11/20/2025

NARRATIVE

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Interviews with residents revealed 6 out of 10 residents stated they have not used the call light button as they are independent and do not need assistance. 2 out of 10 stated staff do not respond right away and it can take them about 30 minutes to respond, 1 out of 10 residents stated they respond right away, and 1 out of 10 residents refused to be interviewed. Interviews with staff revealed staff respond to call light calls within 5-10 minutes. LPA was unable to interview R1 as R1 is no longer at the facility. Documents review revealed physician’s report dated 12/12/22 notes R1 did not need assistance with toileting needs. Independent Service Plan dated 3/11/23 notes R1 needed limited to total assist with activities of daily living (ADLs) including assistance with toileting. Facility's call light system does not track the calls made by the residents. During today’s tour LPA Flores tested call light buttons in 9 resident rooms and a caregiver responded within 1-7 minutes. Although R1 required assistance with toileting at the time of the allegation based on the preponderance of evidence standard there is not enough evidence to say residents are not being assisted in a timely manner.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding allegation: Staff left resident unattended for a period of time. It is alleged resident was left in the bathroom unassisted for an hour and a half. LPA was unable to interview R1 as R1 is no longer at the facility. Interviews with residents revealed 5 out of 10 residents interviewed stated to be independent and do not require assistance. 3 out of 10 residents stated caregivers stay with them when providing assistance until they are done either with showers or toileting. 1 out of 10 residents stated a staff did not stay with them in the bathroom while assisting with shower. 1 out of 10 residents refused to be interviewed. Interviews with staff revealed staff are to stay with the residents while the residents are using the bathroom. Staff use their walkie talkie to communicate to other caregivers that they are assisting a resident and ask if another staff can assist the resident. Incident report dated 12/9/23 notes R1 was assisted to the bathroom and back to R1’s chair. However, R1 used the bathroom alone and staff were unaware that R1 had returned to the bathroom. Although the incident may have happened, we have insufficient evidence to support the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
(CONTINUED ON LIC 9099C)

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20231212144731

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: 11/20/2025

NARRATIVE

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Regarding allegation: Staff did not safeguard resident’s personal belongings. It is alleged resident’s roommate broke R1’s vase and it was not replaced. LPA was unable to interview R1 as R1 is no longer at the facility. Interview with residents revealed 7 out of 10 residents stated to not have lost any valuable items while living at the facility. 2 out of 10 residents stated items have been lost and weren’t sure if they were replaced and 1 out of 10 residents refused to be interviewed. Interviewed with staff revealed residents have not reported items lost or lack of facility’s responsibility for missing items. Per administrator R1 did not sign resident personal property and valuables which list the resident's belongings. Administrator stated that R1’s roommate broke a vase that belonged to R1 by accident. However, there was no reimbursement done as R1's responsible party did not want to pursuit one. Documents reviewed revealed on 8/9/23, R1 signed Windor’s Court policy stating that residents “will not bring to the facility items of a higher value of $25.00 dollars … and will reimburse items valued at $25.00 and under”, as long as they are listed in the resident personal property and valuables. Interviewed with responsible party revealed R1 had a vase that was worth over $250.00 in the shared resident's bedroom. The roommate accidentally pushed a standing divider and broke the vase. However, no one offered to reimburse the cost of the item. Responsible party does not recall filling out documentation to ensure personal belongings were listed. LPA reviewed copy of residents personal property and values for R1 and was not sign and did not have any items listed. Although the incident happened, per documents review R1 signed a document in which acknowledges facility will not reimburse items valued over $25.00. Therefore, the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted with Aurelien Fruit - Administrator and a copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

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