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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800179
Report Date: 10/22/2024
Date Signed: 10/22/2024 05:04:10 PM

Document Has Been Signed on 10/22/2024 05:04 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/
DIRECTOR:		HALL, DARIANFACILITY TYPE:
735
ADDRESS:1386 SANDERS ROADTELEPHONE:
(707) 838-9489
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 4CENSUS: 3DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Tina Rundle-CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst Alviso arrived unannounced to conduct an Annual Required inspection and met with caregiver, Tina Rundle. LPA contacted the Licensee/Administrator Darian Hall; Darian Hall couldn't make it to the facility. Darcy Harlan arrived to the facility to meet with the LPA. Darian Hall, Licensee, arrived to the facility to meet with the LPA.

Darian Hall stated that Darcy Harlan is the Administrator because they/Darian can no longer be the Administrator. Darcy Harlan has a current Adult Residential Administrator certificate #702498735 -expires 3/18/25.

LPA is requesting the Administrator change documents to appoint Darcy Harlan as the facility Administrator. Include the following documentation: As discussed, cover letter requesting a change of Administrator, include effective date, address and contact information. Copy of administrator certificate, and an LIC308 Designation of facility responsibility. Submit an updated LIC500 personnel report of all staff, days and hours on duty.

Per LPA's record reviews, two (2) staff S1 & S2, are not associated to the facility as required. This deficiency will be cited, Criminal Record Clearance 80019(e)(3)(4) -All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 80019(f) or Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility, see LIC809.

The following deficiency was observed 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: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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 10/22/2024 05:04 PM - It Cannot Be Edited


Created By: Dina Alviso On 10/22/2024 at 04:47 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: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)(4)
Criminal Record Clearance 80019(e)(3)(4) All- individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 80019(f) or Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record reviews, S1 & S2 lack association to the facility as required, the licensee did not comply with the section cited above in [2] out of [4] staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee/Administrator to submit criminal record transfer request documentation for S1 & S2 to associate them to the facility as required; Submit LIC9182 transfer form, Valid Identification per LIC9182. POC due 10/23/24.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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