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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804075
Report Date: 04/16/2024
Date Signed: 04/16/2024 04:20:39 PM


Document Has Been Signed on 04/16/2024 04:20 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WINDROSE CARE HOMEFACILITY NUMBER:
496804075
ADMINISTRATOR:SOLOMON, BANAFACILITY TYPE:
740
ADDRESS:1759 WINDROSE LANETELEPHONE:
(707) 852-5025
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 4DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Bana Solomon-AdministratorTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alviso and Mutialu conducted a Required- 1 Year visit, on 4/16/24 at approximately 8:40am, and met with Licensee/Administrator Bana Solomon. There currently are four (4) residents in care.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for six (6) residents. Facility has a required infection control plan. Facility has an emergency and disaster plan as required. The facility does have emergency food, water, and supplies to meet the "72 hour shelter in place" requirements. Facility has a fire clearance approval for a total of six non-ambulatory, of which one (1) may be bedridden.

The LPAs reviewed four (4) resident files. All files were complete.

The LPAs reviewed five (5) staff files. All staff have criminal record clearance. All staff have current first aid and CPR certification as required.

The LPAs toured the facility with the Administrator Bana. The hot water was checked at 114. to 116.6. degrees Fahrenheit , which is within regulation. The fire extinguishers were tagged and serviced as required- expires 2/2/25. All exits were unobstructed. Food supply was sufficient. All bathrooms have grab bars, and non slip flooring for resident use. The facility is well lighted, including all resident rooms and bathrooms. The facility was observed to be at a comfortable temperature. All medications were locked up and not accessible to residents in care. Facility had sufficient furnishings for client use.

Continued on LIC809C..
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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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: WINDROSE CARE HOME
FACILITY NUMBER: 496804075
VISIT DATE: 04/16/2024
NARRATIVE
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The backyard has outside patio furnishings for resident use, table had a large shade umbrella. Fire exit and walkways in the backyard were clear and unobstructed. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. Facility has a sufficient supply of personal protective equipment(PPE). LPA observed sufficient supply of food, perishable and non-perishable food.

LPA is requesting the following documents be updated and submitted by 5/16/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

Per LPA record reviews, five staff out of five staff lacked completed care staff training, consisting of a total of forty hours, this will be cited, HSC 1569.625 (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. see LIC809D.

Per LPA record reviews, there was no documentation of quarterly drills being conducted, the Administrator was not able to provide any documentation of having held emergency quarterly drills, on every shift, as required. This deficiency will be cited, HSC 1569.695(c) A facility shall conduct a drill at least quarterly for each shift, see LIC809D.

LPAs observed that a resident bathroom's sink had a leaking pipe underneath it, this will be cited, Maintenance and Operation 87303(a)-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors, see LIC809D.

Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2024 04:20 PM - It Cannot Be Edited

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: WINDROSE CARE HOME
FACILITY NUMBER: 496804075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, Garage door was not locked, and left all cleaners, soaps, disinfectants, accessible to residents in care, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Licensee to ensure that the cleaners, soaps, and disinfectants are kept locked and inaccessible at all times to residents in care. Submit plan on how this was corrected, include pictures with plan of correction. POC due 4/17/24.
Type A
Section Cited
HSC
1569.69(a)(3)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, staff lack completed required medication training hours, for staff that handle medications, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Licensee will ensure that staff that handle medications have all required medication training per health & safety code. Submit plan of correction for staff to obtain required medication training hours, and submit proof of training by 4/30/24. Plan of correction due 4/17/24.
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2024 04:20 PM - It Cannot Be Edited

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: WINDROSE CARE HOME
FACILITY NUMBER: 496804075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, five (5) out of five (5) care staff lack completed initial 40 hour required training for, 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: 05/06/2024
Plan of Correction
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Licensee to ensure all staff obtain and complete required forty (40) hour training required per health and safety code. Submit proof of staff having completed all training by POC due date of 5/6/24.

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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2024 04:20 PM - It Cannot Be Edited

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: WINDROSE CARE HOME
FACILITY NUMBER: 496804075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record reviews, Administrator was not able to provide any documentation of having held emergency quarterly drills, on every shift, as required, 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: 04/30/2024
Plan of Correction
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Licensee to ensure drills are completed quarterly as required, and document the drills to record them as needed. Submit plan of correction to ensure facility is in compliance by POC due date of 4/30/24.
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation a resident bathroom sink had a leaking pipe undrneath, 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: 04/19/2024
Plan of Correction
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Licensee to ensure the pipe underneath the sink in the resident bathroom gets repaired and/or replaced to ensure it is in good working order. Submit how this was corrected. POC due 4/19/24.
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


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: WINDROSE CARE HOME
FACILITY NUMBER: 496804075
VISIT DATE: 04/16/2024
NARRATIVE
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LPA's observed that the facility didn't have required "Oxygen in use"signage posted, and there is oxygen in use. This will be cited, Gas and Liquid 87618(b)(3)(B)- Oxygen, “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas, see LIC809D.

LPAs observed that the front door and slider patio door's auditory alarms were not working properly. This will be cited, Care of persons with Dementia 87705(j) -The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident, see LIC809D.

LPAs observed that the cleaners, disinfectants , and soaps, were in the garage, no lock on door and/or items listed in locked up, these items were left accessible to residents in care. Storage Space 87309(a)) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients, see LIC809D.

LPAs reviewed records, two out of five staff lacked the required HSC medication training. HSC Medication Training 1569.69 (a)(3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment, see LIC809D.

Deficiencies 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 Lead Caregiver Ana Herron. Appeal rights given to the Lead Caregiver Ana Herron for the Licensee/Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/16/2024 04:20 PM - It Cannot Be Edited

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: WINDROSE CARE HOME
FACILITY NUMBER: 496804075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Gas and Liquid 87618(b)(3)(B)- Oxygen, “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation , the facility didn't have required "Oxygen in Use" signage in appropriate areas, Oxygen is being used in the faciility, 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: 04/19/2024
Plan of Correction
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Licensee to ensure that "Oxygen in Use" signage is posted in and out of the facility; Submit how this was correceted by POC due date 4/19/24.
Type B
Section Cited
CCR
87705(j)
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation of the front door and slider patio door's alams not working properly, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee to ensure that all exits, including the front door and slider door have auditory alarms working as required. Submit plan of correction by due date of 4/19/24.
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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7