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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005443
Report Date: 12/07/2021
Date Signed: 12/07/2021 04:53:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WINDING WAY VILLA, LLC.FACILITY NUMBER:
347005443
ADMINISTRATOR:STROUP, JENNIFERFACILITY TYPE:
740
ADDRESS:4316 ILLINOIS AVENUETELEPHONE:
(916) 671-3278
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
12/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Michelle ReyesTIME COMPLETED:
05:00 PM
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On 12/7/21, Licensing Program Analyst (LPA) Kevin Mknelly, met with house manager, Jessica Adams regarding a recent incident on 11/22/21.

The purpose of this inspection was to conduct a health and safety check following an incident where a combative resident was hit by a caregiver (S1). LPA observed all residents who appeared to have their needs met by the two caregivers present. The staff who hit a resident has been terminated.

LPA requested the following records- For R1, LIC 602, hospice care plan and care notes of injury post 11/22/21. For S1, application, criminal record statement and proof of training. LPA received resident roster and contact number for S2. Records to be provided by 12/8/21.

To date this facility has had no known or suspected Covid-19 positive staff or residents.

As a result of today’s inspection, no deficiencies were noted.


LPA reviewed the report and provided a copy.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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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