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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403366
Report Date: 02/18/2026
Date Signed: 02/18/2026 12:21:16 PM

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
07/30/2021 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210730140741
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: 129DATE:
02/18/2026
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Aurelien Fruit, AdministratorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Facility retained resident requiring a higher level of care.
Resident did not receive medications as prescribed.
Staff did not treat resident with dignity and respect.
Staff did not follow COVID-19 protocol.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Aurelien Fruit, Administrator. The Department's investigation involved interviews with staff and residents and review of records.

On 07-30-2021, Community Care Licensing (The Department) received a complaint report with the following allegations.

It was alleged that facility retained resident requiring a higher level of care. Information received indicated that Staff #1 (S1) told Resident #1 (R1) that the facility was not the right place when R1 arrived from a skilled nursing facility. R1’s relevant party advised S1 that R1 was assessed by the facility nurse. The Department conducted an interview with S1 who stated that the facility did not have an acting nurse from 06-21-2021 to 08-09-2021. S1 did not know who assessed R1 prior to R1’s admission. Continued on LIC9099-C.....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
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-20210730140741
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: 02/18/2026
NARRATIVE
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LPA’s review of R1’s record revealed that R1 arrived on 07-26-2021 and moved out on 07-29-2021. R1 returned to the skilled nursing facility where R1 was transferred from after request was made by the facility staff. R1 had resided for three (3) days at the facility. LPA’s record review revealed that R1’s resident file was no longer available for review. LPA conducted an interview with Staff #2 (S2) who stated that R1’s resident file was no longer available due to expiration of resident record retention periods. Based on record review, the Department’s investigation did not find enough information to corroborate the allegation that facility retained resident requiring a higher level of care. This allegation is unsubstantiated.

It was alleged that resident did not receive medication as prescribed. Information received indicated that R1’s medication did not arrive when R1 moved in from a skilled nursing facility. LPA’s review of R1’s record did not reveal any history of R1’s medication. LPA’s interview with Staff #2 (S2) revealed that R1’s resident file was no longer available due to expiration of resident record retention period. R1’s progress notes were the only record available at the facility. R1 moved in on 07-26-2021 and returned to the skilled nursing facility on 07-29-2021 per R1’s progress notes. The Department conducted an interview with S1 who stated that R1 arrived with a list of medications but without doctor’s order. Doctor’s order for R1 came in from the skilled nursing facility on the day after R1’s arrival. LPA conducted interviews with eight (8) residents, all of whom stated that staff have provided medication dispense services as prescribed. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that resident did not receive medication as prescribed. This allegation is unsubstantiated.

It was alleged that staff did not treat resident with dignity and respect. Information received indicated that facility staff did not assist R1 with feeding. R1’s relevant party observed a food tray next to R1’s bed while R1 was still in bed. LPA’s review of R1’s record revealed that R1’s care plan and assessment were no longer available for review. LPA’s interview with Staff #2 (S2) revealed that R1’s resident file was no longer available due to expiration of resident record retention period. LPA could not determine if R1 required assistance with feeding. LPA conducted interviews with eight (8) residents, all of whom stated staff treat residents with respect. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff did not treat resident with dignity and respect. This allegation is unsubstantiated.

Continued on LIC9099-C....

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210730140741
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: 02/18/2026
NARRATIVE
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It was alleged that staff did not follow COVID-19 protocol. Information received indicated that R1 did not receive COVID-19 test prior to entering the facility and was permitted to eat in the dining room with other residents. LPA conducted review of R1’s records, but R1’s resident file was no longer available for review. LPA conducted an interview with S2 who stated that R1’s records were not available due to expiration of resident records retention periods. R1’s progress notes were the only record for R1. Per the record, R1 arrived on 07-26-2021 from a skilled nursing facility and returned to the skilled nursing facility on 07-29-2021. The Department’s interview with S1 revealed that R1 already had COVID test or vaccination card as R1 came from a skilled nursing facility. The Department’s interviews with S1 and a resident ambassador revealed that staff had followed COVID protocol. LPA conducted interviews with eight (8) residents, all of whom stated that staff have followed COVID protocol. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff did not follow COVID-19 protocol. This allegation is unsubstantiated.

A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.



An exit interview was conducted where a copy of this report was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3