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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800179
Report Date: 09/01/2023
Date Signed: 09/01/2023 10:19:33 AM

Document Has Been Signed on 09/01/2023 10:19 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
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: 3DATE:
09/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Caregiver, Marylis GachuTIME COMPLETED:
10:30 AM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Caregiver, Marylis Gachu. Licensee/Administrator, Darian Hall was unable to come to the facility but was available by phone and gave permission for caregiver to sign report.

LPA initiated a tour of the facility around 9:00 am and observed the following: Upon arrival, LPA noticed a smell that was identified as coming from below the kitchen sink. LPA observed water damage which was most likely causing the smell. Licensee immediately contacted their maintenance person who came to facility to assess. Per conversation with Licensee, they will begin making repairs today. Facility was a comfortable temperature and passageways were free from obstructions though there are areas outside that have some debris. There was one client at home during inspection and two were at day program. Water temperature in sink used by clients measured at 118 degrees F which is within allowable range of 105 to 120 degrees F. Cabinet containing cleaning supplies and other items that could pose a risk were inaccessible to clients in care. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked.

Fire extinguisher is charged but has not been serviced within the last year. Smoke and Carbon Monoxide detectors were tested and operational during this inspection.

Due to Administrator being unavailable, LPA was unable to complete inspection and will return.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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 09/01/2023 10:19 AM - It Cannot Be Edited


Created By: Victoria Bertozzi On 09/01/2023 at 09:34 AM
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: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by having debris around the yard and water damage under the kitchen sink resulting in an obvious smell in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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Per Licensee, facility will begin repairing underneath the sink today. Licensee has an alternant sink that may be used in the meantime. Licensee will ensure that clients are safe during construction. LPA will return to complete inspection and review that repairs have been made and confirm that facility grounds are free of debris.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023


LIC809 (FAS) - (06/04)
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