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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800179
Report Date: 09/09/2021
Date Signed: 09/09/2021 11:24:34 AM

Document Has Been Signed on 09/09/2021 11:24 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 3DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Acting Administrator, Darcy HarlanTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Acting Administrator, Darcy Harlan. Licensee, Darian Hall arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was not screened and discussed the screening process with staff. Staff indicated that all staff and clients are vaccinated and they don't really get visitors so they stopped their screening process. LPA instructed staff to continue to screen visitors per CCL guidelines. Additionally, staff and clients are not having their temperature checked daily. LPA conducted a walk-through of the facility and observed that were not any Covid-19 posters. Per Licensee, clients are verbally reminded to wash and/or sanitize their hands frequently adding that hand washing posters were not effective. LPA told Licensee that posters regarding visitation and screening should be on the front door. Licensee agrees to put up posters. LPA will provide posters if needed. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed in the kitchen accessible to clients in care. Per staff, they regularly discuss infection control with client and staff and facility is disinfected at least once per day. Clients are encouraged to wear masks when in the community.

LPA and Administrator discussed resident activities and visitation. Per discussion with Licensee, staff have not completed PPE training and have not been N-95 Fit tested.

Facility has submitted their Covid Mitigation Plan. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. Facility maintains a 30 day supply of medication.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: WINDSOR HOUSE
FACILITY NUMBER: 496800179
VISIT DATE: 09/09/2021
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Continued from LIC809

100% of staff and clients are vaccinated.

LPA addressed other areas including but not limited to the following:

  • Facility had a lock on the cabinet under the kitchen sink which houses cleaning supplies.
  • Cabinets and drawers containing non-perishable food was observed to be cleaned and food items were not expired. Conversation with staff confirmed that paper was removed from the cabinets that had become soiled and all food had been gone through to remove expired foods.
  • A fire drill was conducted Tuesday, September 7, 2021 per conversation with staff but documentation was not available. Staff was unable to locate the form used to document the drill but will locate form and send to LPA.
  • Licensee's Administrator Certificate recently expired per conversation with Licensee. Acting Administrator has an active Administrator Certificate that expires 9/30/2021. Per conversation with Darcy, they were given a temporary certificate once they completed their classes. They are scheduled to test next week and once they pass, they will received a regular Administrator Certificate. Once received, Licensee plans to send in paperwork for a Change of Administrator.
  • Training was also discussed and LPA provided Licensee with CCL training requirements but indicated that the training by North Bay Regional Center is more extensive and the facility would need to discuss training requirements with the regional center. LPA will return to review training materials.

Administrator and LPA discussed their Emergency Disaster Plan.

LPA requested that Licensee and Administrator review PIN 21-40-ASC.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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