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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403366
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:34:56 PM


Document Has Been Signed on 07/14/2022 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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: 130DATE:
07/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Patrick Mcadoo Morton - AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analsyt (LPA) Crystal Colvin was at the facility conducting an investigation on a complaint (#18-AS-20220706102318) when LPA Colvin observed the following items which were addressed:
  • Reporting Requirements: LPA Colvin learned through record review and interviewed that one resident (R1) was physically violent to multiple residents on numerous dates. R1 punched, kicked, and spat at different residents, all of which was documented in R1's progress notes, but was not reported to Licensing. This behavior was a safety risk and personal rights violation to each resident, and had Licensing been made aware of the ongoing situation, Licensing could have reached out to assist and inquire about the issues with R1 and aided the facility in recommendations for response. Deficiency cited.

  • Record Keeping: In addition to not reporting these incidents to Licensing, the facility staff failed to note in the multiple victims files of the abuse/violence, and therefore, this information was not relayed to the rest of the care staff, and was likely not reported the residents' responsible parties. Deficiency cited.

  • Re-Assessment of Resident(s): R1 was observed to have a marked change in behavior, which was communicated to R1's doctor and Public Guardian, however, the facility failed to conduct an updated assessment of R1 to determine if R1 was still appropriate for their facility. Deficiency cited.

  • Camouflaging of Medication: During LPA Colvin's investigation, LPA Colvin learned that R1 was refusing to take their medication as they "thought it was poison". This resulted in care staff camouflaging R1's medication in their morning juice. LPA Colvin clarified whether or not this was done with R1's knowledge, and it was confirmed that it was done without R1's knowledge and for the express purpose of tricking R1 into taking their medication. Deficiency cited.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2022
NARRATIVE
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Based on LPA Colvin's investigation, the facility was cited and deficiencies noted on LIC809Ds. LPA Colvin conducted an exit interview with Administrator Patrick Mcadoo Morton where a copy of this report, LIC 809Ds, and appeal rights were provided.

****Due to technical issues, reports were signed with ink signatures after they were printed. Facility maintains original copy while LPA maintains a photocopy of the report.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/14/2022 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish.. reports...including...: (1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above regulation with multiple incidents. LPA Colvin observed that R1 was physically violent with other residents multiple times from 6/12/22 - 7/1/22 with only one report (7/1/22) being sent to Licensing. This was an immediate safey risk for all residents.
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Training and Statement of Understanding due by Plan of Correction date of 7/15/22.
Type A
07/15/2022
Section Cited

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Incidental Medical and Dental Care: (a) A plan...provide for assistance in obtaining such care...:(5) Facility staff ...may assist persons...as needed. Assistance...shall be limited to ...: (D) Assistance...does not include...hiding or camouflaging medications...without the resident's knowledge and consent...
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This requirement was not met by: Based on interviews conducted, the Licensee did not comply with the regulation with one resident. Staff administered R1's medication without R1's knowledge by putting it in R1's morning juice due to R1 refusing medication. This was an immediate personal rights violation of R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/14/2022 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited

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Reappraisals: (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff...when there is significant change in the resident’s condition.... This requirement was not met as evidenced by:
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Based on interviews and record review, the Licensee did not comply with the above regulation with one resident. R1 was observed to have a significant change in condition (behavioral) in June 2022, but the facility did not conduct a reappraisal of R1's needs. This was a potential safety risk for R1.
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Type B
07/29/2022
Section Cited

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Additional Personal Rights of Residents...: (a) In addition to the rights listed ...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs.... This requirement was not met as evidenced by:
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Based on record review and interviews, the Licensee did not comply with the above regulations for multiple residents. R1 was reported to have been violent with multiple residents, but the facility failed to document this in the other residents' file. This was a potential personal rights violation of residents.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4