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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800041
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:12:58 PM

Document Has Been Signed on 04/16/2024 02:12 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WINDROSE HOUSEFACILITY NUMBER:
496800041
ADMINISTRATOR/
DIRECTOR:
LOEWEN, VICKIEFACILITY TYPE:
735
ADDRESS:1767 WINDROSE COURTTELEPHONE:
(707) 528-7466
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 3DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Russell Loewen, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Inspection of facility. LPA met with Licensee’s Russ Loewen & Administrator Vicky Loewen.

LPA initiated a tour of the facility at 11:15 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. The amount of fresh and non-perishable foods was within regulation. Additional Emergency food supplies are located in the garage. Water temperature in faucets accessible to clients was within regulatory range of 105 degrees to 120 degrees F. Extra hygiene products are stored in a separate room and linens to accommodate clients are stored in the hallway. Mattress pads were in place or available for client use. Cabinet in laundry room containing cleaning supplies was locked.

Fire extinguisher was last inspected July 11, 2023. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was also tested and operational. Disaster Drills are documented bi-monthly with the last being 2/29/2024. Facility has a generator should the power go out during an outage.

At approximately 12:20 PM, LPA initiated a file review of 3 of 3 Client records and 3 of 3 Staff records, which were all found to be well organized, thorough and contained the required documentation. Staff have required First Aid certificates and Criminal Record Clearance. Sample review of Medications and medication records were reviewed. Medications were centrally stored and locked. P&I monies were documented, secured and not commingled. Administrator Certificate for Vickie Loewen, 6022472735 expires 12/8/2024.

Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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: 04/16/2024
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Continued from LIC809-

LPA Hansen requested updated annual documents to be sent to CCL by 5/4/2024:



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

No deficiencies were observed in the areas inspected. No citations issued during today's inspection

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

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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