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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800179
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:43:09 PM

Document Has Been Signed on 11/06/2024 02:43 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:
11/06/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:32 AM
MET WITH:Tina Rundle-CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Alviso conducted a continued annual inspection, on 11/06/24 at approximately 9:45am, and met with caregiver Marylis Gachu.

All clients were at day program during the inspection. Facility has two (2) client bedrooms. Facility has a fire clearance for three (3) ambulatory clients, and one (1) non-ambulatory client.

LPA reviewed three (3) client files. Medications were reviewed. LPA reviewed four (4) staff files. LPA conducted annual visit on 10/22/24, and cited a deficiency for two (2) staff (S1 & S2) not being associated to the facility as required, Criminal Record Clearance 80019(e)(3)(4), see LIC809D of 10/22/24. The civil penalty for this citation is being assessed today, in the amount of $200, see LIC421BG.
Facility hot water was 120. degrees Fahrenheit. LPA discussed during the inspection, regulation requirement of hot water, it is not to be over 120. degrees or under 105. degrees Fahrenheit. The facility had a sufficient supply of perishable and non-perishable food during the inspection. All smoke alarms were working appropriately during the inspection. All fire extinguishers were serviced and tagged as required.

LPA requested the following forms to be updated and submitted to CCL by 12/6/24:
LIC 9020 Client list
Affidavit Regarding Client Cash Resources
Copy of Surety Bond
Emergency Disaster Plan (review-if changes, submit to CCL)
Infection Control Plan (review-if changes, submit to CCL)

The following observed deficiencies will be cited:
Per LPA interview with staff, and LPA observations, the keys to the medication cabinet are kept in a drawer of a small plastic storage container that is kept on the kitchen counter. LPA obtained pictures. This allows the medication keys to be accessible to clients and all others when the keys are in it; Only staff trained to assist clients with medications, should have access to the medications. LPA obtained photos. Deficiency will be cited, Health Related Services 80075(k)(1)-Centrally stored medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D.
Continued on LIC809C..
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSOR HOUSE
FACILITY NUMBER: 496800179
VISIT DATE: 11/06/2024
NARRATIVE
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Continued from LIC809..
The bathroom curtains do not provide privacy to clients who are bathing/showering and/or using the toilet. LPA Obtained pictures. Deficiency will be cited, Fixtures, Furniture, Equipment and Supplies 85088(b)(4)-Toilet, washbasin, bath and shower fixtures shall at a minimum meet the following requirements: Individual privacy shall be provided in all toilet, bath and shower areas, see LIC809D.

The facility grounds outside had numerous items that are discarded around the property, including broken furniture, glass, and other miscellaneous items/objects. The facility property and pathways need to be cleared of any objects/items, and the overgrowth of grass into walkways, with debris/dirt. The garage has some facility food items, and hygiene items, stored in it, but the garage has numerous items all over the place, it doesn't have a clear pathway/walkway for use by staff or others.
The living room has a cat box full of feces, and some feces on the living room floor. The couch in the living room has no back cushions as needed, and the seat cushions are ripped. The dining room has dirty broken blinds hung up. There is an area in the corner of the ceiling, in the room off the kitchen, that has some damage to it, cracks and what looks like it could have water damage. Under the kitchen sink there is an area that has some water damage from leaks that have occurred this last year, including a few weeks back, per staff interviews. All of the kitchen drawers and cabinets have no knobs on them, there is a hole where the knobs used to be. LPA obtained pictures. Deficiency will be cited, Buildings and Grounds 80087 (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, see LIC809D.

Per facility record reviews, there are no documented disaster drills that have been completed as required by Health & Safety Coode, emergency disaster plan requirements; Staff, S2, stated there are no drills that have been conducted. Deficiency will be cited, HSC 1565(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill, see LIC809D.

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 with caregiver Marylis Gachu. Appeal rights were provided with the LIC809 report.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/06/2024 02:43 PM - It Cannot Be Edited


Created By: Dina Alviso On 11/06/2024 at 01:13 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: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)-
Health Related Services 80075(k)(1)-The following requirements shall apply to medications which are centrally stored: Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Per LPA interview with staff, and LPA observations, the keys to the medication cabinet are kept in a drawer of a small plastic storage container that is kept on the kitchen counter. LPA obtained pictures. This allows the medication keys to be accessible to clients and all others when the keys are in it; Only staff trained to assist clients with medications, should have access to the medications, the licensee did not comply with the section cited above, which poses an immediate health, safety risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee/Administrator to ensure that the medications are centrally stored and locked, ensuring the keys to the lock are secured, and not accessible to clients in care, and others that do not handle medications. Provide how the medications will be centrally stored and the key to the lock will not be accessible to clients in care. Plan of correction due 11/7/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/06/2024 02:43 PM - It Cannot Be Edited


Created By: Dina Alviso On 11/06/2024 at 01:20 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: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(b)(4)
Fixtures, Furniture, Equipment and Supplies 85088(b)(4)-Toilet, washbasin, bath and shower fixtures shall at a minimum meet the following requirements: Individual privacy shall be provided in all toilet, bath and shower areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA observations, the bathroom curtains do not provide privacy to clients who are bathing/showering and/or using the toilet. the licensee did not comply with the section cited above, which poses/posed a personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
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Licensee/Administrator to ensure that the resident's bathroom has blinds, shade or curtains that will provide the expected privacy to all clients using the bathroom, including use of toilet and bathing/showering. Plan of correction due 11/11/24.
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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/06/2024 02:43 PM - It Cannot Be Edited


Created By: Dina Alviso On 11/06/2024 at 01:26 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: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds 80087 (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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Per LPA observations, the facility grounds outside had numerous items that are discarded around the property, including broken furniture, glass, and other miscellaneous items/objects. The facility property and pathways need to be cleared of any objects/items, and the overgrowth of grass into walkways, with debris/dirt. The garage has some facility food items, and hygiene items, stored in it, but the garage has numerous items all over the place, it doesn't have a clear pathway/walkway for use by staff or others. The living room has a cat box full of feces, and some feces on the living room floor. The couch in the living room has no back cushions as needed, and the seat cushions are ripped. The dining room has dirty broken blinds hung up. There is an area in the corner of the ceiling, in the room off the kitchen, that has some damage to it, cracks and what looks like it could have water damage. Under the kitchen sink there is an area that has some water damage from leaks that have occurred this last year, including a few weeks back, per staff interviews. All of the kitchen drawers and cabinets have no knobs on them, there is a hole where the knobs used to be. LPA obtained pictures, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Licensee/Administrator to ensure that all items listed in the deficiency citation above are addressed appropriayely, cleaned, repaired, discarded and removed off facility property as needed and required; Ensure the facility inside and outside is clean, safe, sanitary, and in good repair as required by law/regulations. Plan of correction in how facility will be broughti nto compliance regarding above corrections needed. Include in the planwhat may already be corrected and how it was, and list all other items that will be corrected, and how by POC due date of 11/13/24. Corrections will need to all be completed by follow-up date of 12/6/24. POC due 11/13/24, follow-up proof of corrections 12/6/24.
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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/06/2024 02:43 PM - It Cannot Be Edited


Created By: Dina Alviso On 11/06/2024 at 02:17 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: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1565(c)
HSC 1565(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per facility record reviews, there are no documented disaster drills that have been completed as required by Health & Safety Coode, emergency disaster plan requirements; Staff, S2, stated there are no drills that have been conducted, the licensee did not comply with the section cited above, which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee/Administrator to submit plan of facility conducting required emergency disaster drills per HSC 1565(c); Facility to conduct a disaster emergency drill, and submit this documented drill with the facility plan. Administrator to ensure all other drills are conducted as required, quarterly, including an evacuation drill. POC due 11/22/24.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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