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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800179
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:40:09 PM

Document Has Been Signed on 09/19/2023 12:40 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: 3DATE:
09/19/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Licensee/ Administrator, Darian HallTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to conduct a Case Management Annual Continuation inspection and met with Licensee/ Administrator, Darian Hall.

LPAs returned to continue inspection that was initiated on 09/01/2023.

Upon arrival, LPAs conducted a file and medication review. Three client files and one staff file was reviewed. Reviewed staff does not have required First Aid certificate. Files for all other staff were unavailable.

Licensee does not have an active Administrator Certificate though they are listed as the Administrator. Per discussion with Licensee, the acting Administrator is Darcy Harlan. Administrator Certificate for Darcy Harlan 6059139735 has expired but is on the Department's pending list.

One of three clients did not have a completed Centrally Stored Medication Log so LPAs were unable to audit their medication. Two of three clients did not have an accurate number of medication doses and the dates on the Centrally Stored Medication appeared to be inaccurate with some having a start date prior to the fill date.

Fire extinguishers were last serviced June 2021. LPAs reminded Licensee that fire extinguishers are to be serviced annually.

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: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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 09/19/2023 12:40 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 09/19/2023 at 11:31 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: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
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:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee agrees to submit proof of first aid certificate by POC due date 09/20/2023.
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: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/19/2023 12:40 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 09/19/2023 at 11:31 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: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in five out of five persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee agrees to ensure files are complete and available at facility no later than POC due date 10/02/2023. LPA to return to review files at a later date.
Type B
Section Cited
CCR
80075(k)(7)
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 and includes the following:
(A) The name of the client for whom prescribed, (B) The name of the prescribing physician, (C) The drug name, strength and quantity, (D) The date filled, (E) The prescription number and the name of the issuing pharmacy, (F) Expiration date, (G) Number of refills, (H) Instructions, if any, regarding control and custody of the medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 clients medication records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee agrees to audit and update centrally stored log so it is current and accurate by POC due date. LPA to return to review at a later date.
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: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023


LIC809 (FAS) - (06/04)
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