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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800179
Report Date: 09/15/2022
Date Signed: 09/15/2022 10:56:56 AM

Document Has Been Signed on 09/15/2022 10:56 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:WINDSOR HOUSEFACILITY NUMBER:
496800179
ADMINISTRATOR:HALL, DARIANFACILITY TYPE:
735
ADDRESS:1386 SANDERS ROADTELEPHONE:
(707) 838-9489
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 4CENSUS: 3DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator, Darcy HarlanTIME COMPLETED:
11:06 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Administrator, Darcy Harlan. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff including having temperature checked. Per Administrator, clients don't really get visitors that visit inside the facility but they screen visitors. LPA discussed conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC with Administrator. LPA initiated a walk-through of the facility around 8:45 am and observed the following: Facility was a comfortable temperature and exits were free from obstructions. There is notification on the front door notifying visitors that they will be screened upon entry. LPA discussed the lack of posters in the facility with the Administrator who explained that staff must verbally remind clients to wash their hands and socially distance. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected daily. LPA reminded Administrator to document daily screening for staff and clients and for when visitors come to the facility.

Facility has a designated visitation area outside and is allowing for visitation inside facility per CCL guidance. LPA discussed ensuring that training for infection control and proper donning and doffing of PPE is incorporated into their annual training. Per Licensee, they frequently go over donning and doffing of PPE with staff. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including gloves, masks and hand sanitizer. LPA suggested getting gowns in case a client becomes positive. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced July 2021. Smoke and carbon monoxide detectors throughout facility were tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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: WINDSOR HOUSE
FACILITY NUMBER: 496800179
VISIT DATE: 09/15/2022
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Continued from LIC809

Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan.



Licensee/Administrator to submit updates of the following documents by 10/15/2022.:
LIC 500 Personnel Summary
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan (If changes)
LIC 9020 Register of Facility Client’s/Resident’s

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

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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