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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802025
Report Date: 05/25/2021
Date Signed: 05/25/2021 10:46:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BROOKDALE WINDSORFACILITY NUMBER:
496802025
ADMINISTRATOR:WATSON, WENDYFACILITY TYPE:
740
ADDRESS:907 ADELE DRTELEPHONE:
(707) 837-8785
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:80CENSUS: 58DATE:
05/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Administrator, Wendy WatsonTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Administrator, Wendy Watson. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has hand sanitizer outside of the entrance to the facility and once inside the facility, the receptionist checked LPA's temperature and asked standard Covid-19 Screening questions. Visitor log is completed by the receptionist. LPA conducted a walk-through of the facility with the Administrator and observed Covid-19 posters throughout the facility that included hand-washing signs in each public bathroom. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility and outside of each resident's room. Per Administrator, they regularly discuss infection control with residents and staff. Residents are encouraged to wear masks when outside of their rooms and staff are required to wear them while in the facility. Observed staff had masks on during this visit.

Facility is allowing for 25% of residents to dine at a time and dining furniture is set up for social distancing. Some residents prefer to eat in their rooms and that is being accommodated. Common areas are also set up for social distancing. LPA and Administrator discussed resident activities and visitation.

Facility staff have completed PPE training and have been N-95 Fit tested. Administrator showed LPA documentation of training and disinfection. Commonly touched surfaces are disinfected three times per day and logged. Dining room table and chairs are disinfected between residents. Public bathrooms and employee break rooms are disinfected after use.

Facility has submitted and received approval for their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, face shields, gowns and hand sanitizer.

LPA confirmed that Administrator has reviewed PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, ect.



Administrator and LPA discussed their Emergency Disaster Plan

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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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