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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800179
Report Date: 09/09/2025
Date Signed: 09/09/2025 04:48:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250905085117
FACILITY NAME:WINDSOR HOUSEFACILITY NUMBER:
496800179
ADMINISTRATOR:GACHU, MARYLISFACILITY TYPE:
735
ADDRESS:1386 SANDERS ROADTELEPHONE:
(707) 838-9489
CITY:WINDSORSTATE: ZIP CODE:
95492
CAPACITY:4CENSUS: 2DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Marylis Gachu, Administrator
Darcy Harlan, Staff Member		TIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Licensee did not keep a Centrally Stored Medication Record for clients in care
Licensee did not keep facility safe, clean, sanitary and in good repair
Licensee did not ensure staff had First Aid training
Licensee did not ensure clients were assisted as needed with self-administration of medications
INVESTIGATION FINDINGS:
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At approximately 9:05 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with facility Administrator Marylis Gachu and Staff Member Darcy Harlan

Complaint alleges licensee did not keep Centrally Stored Medication and Destruction records for clients in care. During the investigation LPA audited Medications and Centrally Stored Medication and Destruction records for clients C1 and C2. LPA observed that the facility did not have any Centrally Stored Medication and Destruction records for client C2. LPA asked the facility Administrator if there were Centrally Stored Medication and Destruction records for C2. The Administrator replied that there were not Centrally Stored Medication and Destruction records for C2.

Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20250905085117
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSOR HOUSE
FACILITY NUMBER: 496800179
VISIT DATE: 09/09/2025
NARRATIVE
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...Continued from 9099
LPA further observed that client C1 did have Centrally Stored Medication and Destruction records but there was no medication expiration date on C1's Centrally Stored Medication and Destruction records. LPA has photographic evidence of the Centrally Stored Medication and Destruction record for C1. Based on LPA’s interviews, observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Complaint alleges licensee did not keep facility safe, clean, sanitary and in good repair. During an inspection of the facility LPA made the following observations: An extremely strong mildew/mold odor emanated from the front entrance area and in the closet next to the front door. There was a damaged drawer in the kitchen with exposed nails. The area under the kitchen sink was observed to have mold and mildew. There was a large hole in the wall directly above the refrigerator. The cabinet above the refrigerator was damaged. There was a broken window next to the rear door in the kitchen area. The ceiling in the front dining area was peeled back from water damage. There were full trash bags lying on the ground on the side of the house. There was various debris throughout the yard area. The bathtub caulking was peeling and was covered in mildew. LPA has photographic evidence of all observations noted above. Based on LPA’s observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.



Complaint alleges Licensee did not ensure staff had First Aid training. During facility inspection, LPA audited staff personnel records. Three (3) of four (4) staff personnel records were observed to have proof of First Aid Training. LPA observed that staff member S4 did not have personnel records at the facility. The facility is being cited for not having S4's personnel records on their annual inspection report. As staff member S4 had no personnel records at the facility, there is no proof that staff member S4 has First Aid training. Based on LPA’s observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Continued on 9099-C2...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250905085117
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSOR HOUSE
FACILITY NUMBER: 496800179
VISIT DATE: 09/09/2025
NARRATIVE
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...Continued from 9099-C

Complaint alleges Licensee did not ensure clients were assisted as needed with self-administration of medications. During the investigation LPA audited Medications and Centrally Stored Medication and Destruction records for clients C1 and C2. LPA also reviewed the Medication Administration Records (MARs) for clients C1 and C2. While reviewing client medications, LPA was informed that a medication for client C1 had run out the previous day on 9/8/2025 and that C1 was unable to take their medication on 9/9/2025 as directed by their primary care physician. The medication was delivered during the LPA's inspection. The licensee should have ensured their client's medication was refiled in a timely fashion so as to ensure that the clients in care may take their prescription medications per their primary care physician's orders. Based on LPA’s interview and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-9099Ds, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Staff Member Harlan. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20250905085117
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSOR HOUSE
FACILITY NUMBER: 496800179
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2025
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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Licensee to submit a plan on how they will address each issue noted in the LIC9099 to Community Care Licensing by POC due date of 9/10/2025.
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Based on observation, the licensee did not comply with the section cited above in that there was many instances of the facility not being clean, safe, sanitary and in good repair (Reference the LIC9099 for a full list) which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250905085117
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSOR HOUSE
FACILITY NUMBER: 496800179
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2025
Section Cited
CCR
80075(f)
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80075 Health Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
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Licensee will submit a valid First Aid certification for staff member S4 to Community Care Licensing by POC due date of 9/30/2025.
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Based on observation and record review, the licensee did not comply with the section cited above in that staff member S4 did not have a valid First Aid certification in their personnel file which poses an potential health, safety or personal rights risk to persons in care.
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Type B
09/30/2025
Section Cited
CCR
80075(k)(7)(F)
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80075 Health Related Services
(k)...shall apply to medications which are centrally stored:(7)The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications...and includes the following:
(F)Expiration date.
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Licensee to submit completed Centrally Stored Medication and Destruction records for clients C1 and C2 to Community Care Licensing by POC due date of 9/30/2025.
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This requirement is not met as evidenced by:Based on observation & record review, the licensee did not comply with the section cited above in that S2 had no central storage log and S1's Central storage log was missing expiration dates which poses an potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5