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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880707
Report Date: 09/13/2024
Date Signed: 09/13/2024 11:00:43 AM

Document Has Been Signed on 09/13/2024 11:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WINDROSE HOUSE, THEFACILITY NUMBER:
361880707
ADMINISTRATOR/
DIRECTOR:		ELIZABETH GONZALEZFACILITY TYPE:
735
ADDRESS:7411 WINDROSE DRTELEPHONE:
(909) 280-3285
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 4DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Crystal BuenoTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Magda Malcore and Eldin Serrano made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with House Manager, Crystal Guzman and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (4). The facility is a certified Inland Regional Center vendor. LPAs conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. The facility is equipped with operating smoke/carbon monoxide alarms and telephone service. The facility has sufficient supply of bed linen, towels, and hygiene products for clients in care. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space and bedroom lighting. Client bathroom equipment were operating in safe conditions. The hot water in client bathrooms tested at 119 degrees F. LPA's observed no night lights in the hallway in leading to client bathroom. The facility has posted in a common area: Community Care Licensing complaint poster, facility license, house rules, and emergency telephone numbers. The facility's insurance, disaster drill and infection control plan is up-to-date.

Care and Supervision: The facility has 24 hour/7 days a week care staff.

Food Service: The facility’s dining areas, kitchen, and dishware utilized by clients were maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care. LPA's observed in the kitchen area an unlocked cabinet containing sharp knives. LPA's observed staff immediately locked the cabinet during LPA's visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WINDROSE HOUSE, THE
FACILITY NUMBER: 361880707
VISIT DATE: 09/13/2024
NARRATIVE
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Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked closet.

Personnel/Client Records: Staff records reviewed had health screenings, criminal record clearances, and first aid/CPR training certification. Client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs. LPA's review of clients records reveal, client #1 (C1) and client#2 (C2) records of cash resources (P&I) were inaccurate and had funds overage.

Based on LPA's observations and record review, deficiencies are being cited in accordance with Title 22 of the California Code of Regulations. A technical advisory was also issued.

An exit interview was conducted were the licensing reports and a plan of correction was discussed. Copies of the reports and appeal rights were provided to the house manager at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/13/2024 11:00 AM - It Cannot Be Edited


Created By: Magda Malcore On 09/13/2024 at 10:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WINDROSE HOUSE, THE
FACILITY NUMBER: 361880707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs, the licensee did not comply with the section cited above by LPA's observed in the kitchen area an unlocked cabinet containing sharp knives;which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2024
Plan of Correction
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During LPA's visit staff locked the cabinet. No futher action is required.
Section Cited
Activities
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/13/2024 11:00 AM - It Cannot Be Edited


Created By: Magda Malcore On 09/13/2024 at 10:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WINDROSE HOUSE, THE
FACILITY NUMBER: 361880707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above by not maintaining nighlights in hallway leading to client bathroom; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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The Licensee shall submit proof of nightlights to the licensing agency by POC due date.
Section Cited
Safeguards for Cash Resources, Personal Property and Valuables
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/13/2024 11:00 AM - It Cannot Be Edited


Created By: Magda Malcore On 09/13/2024 at 10:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WINDROSE HOUSE, THE
FACILITY NUMBER: 361880707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above by not maintaining accurate account of Client #1 and Client #2 cash funds (P&I); which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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The Licensee/Adminstrator shall provide inservice staff training on accounting records and logs and submit proof of training to the licensing agency by POC due date.
Section Cited
Client Records
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6