336403366-1-24-2022-18-AS-EMAN-CB7Q7W-20220131105548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336403366
Report Date: 01/24/2022
Date Signed: 01/24/2022 12:24:07 PM

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
09/17/2020 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200917115303

FACILITY NAME:	WINDSOR COURT ASSISTED LIVING		FACILITY NUMBER:	336403366
ADMINISTRATOR:	BRITTANY HOLM		FACILITY TYPE:	740
ADDRESS:	201 S. SUNRISE WAY		TELEPHONE:	(760) 327-8351
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	130	CENSUS: 111	DATE:	01/24/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Patrick McAdoo-Morton		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff neglect led to resident sustaining multiple pressure injuries
Resident left in soiled diapers for an extended period of time
Staff failed to meet resident's needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to Administrator, Patrick McAdoo-Morton, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with staff and residents.

In regards to allegation #1, LPA Williams interviewed Staff # (S1) and Staff #2 (S2) who both stated that Resident #1 (R1) had pressure injuries while residing at the facility. S1 stated that they believe the pressure injuries were in Stage 1, while S2 stated that they were unaware of which stage R1's pressure injuries were in. Both S1 and S2 stated that R1's pressure injuries were being cared for by a home health agency, who came to the facility twice a week. S1 stated that R1 was sent to the emergency room, and consequently a skilled nursing facility, several times due to the worsening of R1's pressure injuries. LPA Williams interviewed R1, who stated that they did have pressure injuries of an unknown stage while residing at the facility. R1 stated that a home health agency provided care for the pressure injuries twice a week while at the facility. R1 stated

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

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-20200917115303

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: 01/24/2022

NARRATIVE

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that the facility staff were in constant communication with their health providers and also sent R1 to the emergency room once pressure injuries worsened. LPA Williams reviewed documentation from the facility in which it appeared that a home health agency was caring for R1's pressure injuries. In addition, the documentation appeared to show that facility was in constant communication with R1's health care providers and sought a higher level of care for R1's pressure injuries when needed.

In regards to allegation #2, LPA Williams interviewed S1, S2, and Staff # (S3) who denied that residents are left in soiled diapers for extended periods of time. S1, S2, and S3 stated that the facility staff check/change incontinent residents every two hours or as needed. LPA Williams interviewed R1, who stated that they do not recall an incidence where they were left in a soiled diaper for an extended period of time. LPA Williams also interviewed Resident #2 (R2) who denied that any incidence where they were left in a soiled diaper for an extended period of time. R2 stated that facility staff are meeting their incontinence needs appropriately.

In regards to allegation #3, LPA Williams interviewed S1, S2, and S3, who all stated that resident care needs are being met appropriately. S1 stated that there is sufficient staffing to care for residents and appropriate training provided to facility staff regarding resident care. LPA Williams interviewed R1 and R2 who both stated that their care needs are being met while residing at the facility. R1 stated that they have "no complaints with the facility." R2 stated that facility staff "are doing a great job."

Based on evidence obtained during the investigation, LPA Williams has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to the Administrator at the conclusion of the investigation.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

LIC9099 (FAS) - (06/04)

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