496802025-4-22-2022-21-AS-VWIS-CDQQ48-20220422114956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802025
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:50:15 AM

Document Has Been Signed on 04/22/2022 11:50 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BROOKDALE WINDSOR		FACILITY NUMBER:	496802025
ADMINISTRATOR:	WATSON, WENDY		FACILITY TYPE:	740
ADDRESS:	907 ADELE DR		TELEPHONE:	(707) 837-8785
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	80	CENSUS: 52	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Wendy Watson		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 a hand sanitizer outside of front door and posters related to Covid-19 on the front door. Upon entry, LPA was screened by the receptionist. Per conversation with receptionist, all visitors are screened and vaccination verification is being conducted per Provider Information Notice (PIN) 22-07-ASC. LPA initiated a walk-through of the facility around 9:30am and observed the following: Facility has reduced the amount of Covid-19 posters throughout the facility but does maintain hand washing signs in public bathrooms and Covid-19 posters at the entrance. Per conversation with Administrator, they have removed some signs to provide some normalcy to residents. LPA has requested that some posters are put back up in areas where residents congregate, like the elevators and the activity rooms to remind residents about social distancing and infection control. Infection control is regularly discussed with residents and residents are encouraged to wear masks when outside of their rooms. Facility staff are required to wear masks while in the facility. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas and hallways of the facility. Commonly touched surfaces are disinfected three times per day. Facility maintains documentation of staff and resident daily temperatures. During facility walk through, LPA observed a resident room that had a sign indicating that security cameras were in use. LPA confirmed with Administrator that the resident had cameras in their room. LPA and Administrator discussed the facility creating a policy related to resident camera use to ensure the personal rights of all residents. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE WINDSOR	FACILITY NUMBER: 496802025
	VISIT DATE: 04/22/2022

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Continued from LIC809

LPA and Administrator discussed visitation and activities. Per Administrator, residents are still encouraged to social distance during activities and the groups are small. PIN 21-49-ASC has the most recent guidance regarding group activities. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Facility staff continue to be trained on Covid-19 including but not limited to donning and doffing of PPE and infection control and have been N95 fit tested.

Facility has submitted and Community Care Licensing (CCL) has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced November 2021. Facility has carbon monoxide detectors throughout the facility and the fire alarm system is maintained by a vendor with the last service being conducted February 2022.

Administrator and LPA discussed their Emergency Disaster Plan and the new Infection Control Plan that all facilities must submit to CCL by June 30, 2022. Administrator provided LPA with a copy of the Liability Insurance for the facility.

Administrator to submit updates of the following document by 05/22/2022:

LIC 500 Personnel Summary

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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