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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800179
Report Date: 11/03/2023
Date Signed: 11/03/2023 03:09:51 PM

Document Has Been Signed on 11/03/2023 03:09 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WINDSOR HOUSEFACILITY NUMBER:
496800179
ADMINISTRATOR:HALL, DARIANFACILITY TYPE:
735
ADDRESS:1386 SANDERS ROADTELEPHONE:
(707) 838-9489
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 4CENSUS: DATE:
11/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Direct Support Professional, Marylis GachuTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Case Management inspection and met with staff, Marylis Gachu. Licensee/Administrator, Darian Hall was available by phone.

LPA has returned to review staff files, that were unavailable during the Annual Continuation inspection dated. September 19, 2023 including, but not limited to, First Aid and CPR Certificates and the Centrally Stored Medication Log.

Review of records show that three of three staff have active First Aid and CPR Certificates. One of three staff have the results of a TB test. Three of three staff do not have a health screening form in their file.

LPA reviewed the Centrally Stored Medication Log for 2 of 3 clients as the third client did not have a completed Centrally Stored Medication Log. The medication on hand does not match the Centrally Stored Medication Log. LPA discussed with staff the importance of documenting missed medication and ensuring that the Centrally Stored Medication Log is filled out entirely.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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Document Has Been Signed on 11/03/2023 03:09 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 11/03/2023 at 01:54 PM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSOR HOUSE
FACILITY NUMBER: 496800179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
80066(a)

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80066 Personnel Records (a) Licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following: ...(2) Driver's license number if the employee is to transport clients. (3) Date of employment...
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Facility will update all staff files to meet regulation 80066 no later than POC due date, 11/17/2023 and submit self-certification to CCL indicating that the files are complete.
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(6) Documentation of the educational background, training and/or experience...(8) Employee duties...(10) A health screening.(11) TB test documents. This requirement was not met based on record review showing that 3 of 3 staff files were incomplete. This is a potential risk to health and safety.
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Type B
11/17/2023
Section Cited
CCR80075(k)(7)

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80075 Health Related Services n(k)(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year..This requirement was not met as evidenced by: review of Centrally Stored Medication Log showed that 1 of 1
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Facility to fill out the Centrally Stored Log in it's entirety to reflect medication on hand and submit self-certification that medication documentation is accurate by POC due date, 11/17/2023.
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client does not have a completed log and 2 of 3 clients do not have an accurate medication count based on the Centrally Stored Medication Log. This is a potential risk to the health and safety of clients 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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
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