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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800041
Report Date: 04/21/2023
Date Signed: 04/21/2023 11:29:16 AM

Document Has Been Signed on 04/21/2023 11:29 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 HOUSEFACILITY NUMBER:
496800041
ADMINISTRATOR:LOEWEN, VICKIEFACILITY TYPE:
735
ADDRESS:1767 WINDROSE COURTTELEPHONE:
(707) 528-7466
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 3DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Licensee Russell LoewenTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Required Inspection of facility. LPA met with Licensee Russ Loewen, Licensee/Administrator.

LPA initiated a tour of the facility at 8:45 AM of the building and grounds which was found to be clean and in good repair. LPA made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in faucets accessible to clients was within regulatory range of 105 degrees to 120 degrees Fahrenheit. Extra hygiene products are stored in a separate room and Linens to accommodate clients are stored in the hallway. Cabinet in laundry room containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods for current census. Additional Emergency food supplies are located in the garage.

Fire extinguisher was last inspected June 3, 2022. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was present. Disaster Drills are documented bimonthly with the last being 2/28/2023. A Recreation Therapist visits once a month and additional activities occur following an Activity Schedule.

File review was initiated at 9:30 AM. 2 staff files and 3 client files were reviewed. Staff have required First Aid certificates and Criminal Record Clearance. Administrator Certificate for Vickie Loewen, 6022472735 expires 12/8/2024. Sample Medications and medication records were reviewed. Medications were centrally stored and locked.

No citations issued during today's inspection

Continued on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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: 04/21/2023
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LPA Hansen requested updated annual documents to be sent to CCL by 5/4/2023:

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

Control of Property – Copy of Deed/Lease

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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