496800041-4-22-2022-21-AS-SHAN-CDQPJQ-20220422112156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800041
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:22:05 AM

Document Has Been Signed on 04/22/2022 11:22 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	WINDROSE HOUSE		FACILITY NUMBER:	496800041
ADMINISTRATOR:	LOEWEN, VICKIE		FACILITY TYPE:	735
ADDRESS:	1767 WINDROSE COURT		TELEPHONE:	7075287466
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 4		CENSUS: 3	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Licensee Russell Loewen & Administrator Vickie Loewen		TIME COMPLETED:	11:21 AM

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License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required – 1 year Infection Control Inspection of the facility. LPA was welcomed by Licensee Russell Loewen for the visit. There is a total of 3 clients at the facility who normally attend day programs, but they have not reopened yet.

Tour began at 9:45AM: LPA toured facility with Administrator Vickie Loewen. All visitors are screened upon entering the building; All visitors have their temperatures taken and answer all screening questions. Clients are screened daily and observed for any changes. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire extinguisher was serviced and tagged, 5/25/21. Toxins are stored inaccessible and in locked cabinets. Medications were centrally stored locked making them inaccessible to clients and staff that do not handle medications in kitchen cabinet. Food supply was sufficient. There was a sufficient supply of cleaners, paper products, and hygiene supplies. Water temperature in faucets accessible to clients was within regulatory range of 105 degrees to 120 degrees Fahrenheit. Facility conducts disaster drills bi-monthly with the last drill on February 25,2022.

Infection Controle:

Facility has submitted a mitigation program plan that was approved, 7/28/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. The facility has a sufficient supply of personal protective equipment (PPE) stored in front hallway dresser and garage. Staff had all PPE training required as well have been N95 Fit Tested. All staff and clients have been fully vaccinated and received their COVID booster shots.

Continued on LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDROSE HOUSE	FACILITY NUMBER: 496800041
	VISIT DATE: 04/22/2022

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LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

Administrator Certificate for Vickie Loewen Cert #6022472735 Exp. 12-08-2022

No deficiencies cited today.
Exit interview conducted with Licensee/Administrator Vickey Loewen.

LPA requested additional updated forms to be sent to CCL by May 10, 2022:

LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Client Cash Resources
LIC 402 Surety Bond
LIC610 Emergency Disaster form

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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