<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880707
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:35:49 PM

Document Has Been Signed on 08/24/2023 12:35 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
, CA 92507
FACILITY NAME:WINDROSE HOUSE, THEFACILITY NUMBER:
361880707
ADMINISTRATOR:ELIZABETH GONZALEZFACILITY TYPE:
735
ADDRESS:7411 WINDROSE DRTELEPHONE:
(909) 280-3285
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 0DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Crystal Guzman - Direct Support StaffTIME COMPLETED:
12:38 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 10:07 AM, LPA Anna Bueno arrived at the facility to conduct an unannounced required annual inspection. LPA attempted to gain access to the facility between 10:07 AM and 10:28 AM: LPA rang doorbell and knocked on the door but it was not answered. LPA phoned the facility at 909-280-3285 and phoned administrator Elizabeth Gonzalez. Staff arrived at 10:28 AM and LPA identified herself to staff Crystal Guzman who was advised of the purpose of the visit and administrator Elizabeth Gonzalez arrived during the visit..

The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients. Clients were briefly at the home and left immediately during today's visit.

LPA and staff toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded patio area for clients. The facility had a working telephone for client use. The facility fire extinguishers were last inspected on 01/21/2023. Staff tested smoke alarms and carbon monoxide detectors and LPA observed all units to be in working order. A locked centralized closet utilized for medications and client files. Sharps, toxins, and cleaning agents are kept locked and secured.


The following were observed of the physical plant:

Client Bedrooms and Bathroom: LPA and Administrator observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens. LPA and Administrator observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. The facility keeps a supply of hygiene provisions.
***SEE LIC-C***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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
, CA 92507
FACILITY NAME: WINDROSE HOUSE, THE
FACILITY NUMBER: 361880707
VISIT DATE: 08/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Kitchen and Dining Areas: LPA and Administrator inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. The facility menu is available for review. LPA and Administrator observed at least two (2) days supply of perishable food items and 7 days supply of nonperishable food items. The facility menu was available for review. The kitchen countertop, floors, and appliances were free from debris.
Common (living/activity) areas: LPA and Administrator observed night adequate seating in the common areas. The facility had a supply of activities for the clients. Calendar of activities were reviewed.


The following records were inspected:

Client Records: LPA inspected all client files and found that it had the required documentation including an admissions agreement, physician's report, and Individual Program Plan (IPP).
Staff Records: LPA reviewed all staff files and found current first aid certifications and training verifications. The administrator certificate is current.
Centralized Medication: LPA reviewed all client medications and found that the medication is being administered as prescribed.
LPA also reviewed updated LIC 500, personnel report, and LIC 610E, emergency disaster plan.

No deficiencies were issued during today's visit. An exit interview was conducted where this report was discussed and a copy was provided to administrator Elizabeth Gonzalez at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2