<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602798
Report Date: 03/05/2024
Date Signed: 03/05/2024 03:10:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2023 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230712142353
FACILITY NAME:WINDSOR HALL CARE HOME INC.FACILITY NUMBER:
197602798
ADMINISTRATOR:HONEYLETT URREAFACILITY TYPE:
735
ADDRESS:1415 W. JAMES WOODTELEPHONE:
(213) 383-1547
CITY:LOS ANGELESSTATE: CAZIP CODE:
90015
CAPACITY:82CENSUS: 71DATE:
03/05/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Honeylet UrreaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to notify responsible party of incidents involving client
Lack of care and supervision resulted in resident being physically assaulted by another client causing significant injuries
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Honeylet Urrea and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 07/13/23, LPA Gonzalez collected copies of Staff and Client rosters. LPA conducted a tour of entire facility inside and out with Assistant Administrator Antonieta Dulay. Facility tour consisted of observations of common areas, dining room, random client rooms, bathrooms, patio area and kitchen. LPA observed client in the facility, some clients were out in the patio area, in their rooms, in the lobby and dining room at the time of the visit. LPA observed the clients to identify any signs of neglect, abuse or other immediate Health and Safety threats. LPA did not observe any immediate Health & Safety concerns during the visit.

(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20230712142353
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WINDSOR HALL CARE HOME INC.
FACILITY NUMBER: 197602798
VISIT DATE: 03/05/2024
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
26
27
28
29
30
31
32
On 03/05/24, LPA Gonzalez collected copies of Staff and Client rosters, reviewed C1's file and collected copies of documents pertinent to the investigation. LPA additionally interviewed Clients 1-7 (C1-7) and Staff 1-4 (S1-4).

Investigation revealed the following: Regarding allegation, Facility failed to notify responsible party of incidents involving client, it is alleged that facility staff failed to inform C1's family member of C1's hospitalization on 06/06/23 and that C1 was also missing for 3 weeks and facility did not notify C1's family member of any updates. Interviews with Administrator Urrea, and S1-3 revealed that C1 was hospitalized on 06/06/23 and the staff immediately notified C1's family member. They stated that they continued to follow up with the hospital regarding C1's status and to get updates. They stated that on 06/08/23 when following up with the hospital they were notified by hospital staff that C1 was discharged and sent home. Staff checked the facility and C1 was not in the facility. Facility filed a missing person police report and also informed C1's family member. Staff stated that C1 eventually returned to the facility on 06/20/23 and was sent to the hospital for a well-ness check and discharged back to the facility on 06/26/23. Staff stated that C1's family member was notified of C1's return as well as C1 being sent to the hospital for a well-ness check and then their discharge. Interviews with staff revealed that facility staff keep family members, responsible parties and conservators (if any) notified of any incidents involving clients. Administrator stated that an unusual incident report was created and submitted to Community Care Licensing (CCL) within 7 days per regulation. She stated that C1's family member and placement agency were also notified of any incidents involving C1. She stated that the same procedure is followed for any client. She also stated that C1 is still a client of the facility. Interviews conducted with 4 out of 4 staff revealed that facility staff create and submit unusual incident reports to CCL within 7 days, and facility notifies responsible parties of any incident. LPA review of documents revealed that the facility completed and submitted incident reports to CCL in a timely manner as well as notified responsible party of incident(s) involving C1. Unusual Incident/ Injury Reports reviewed are dated 06/06/23, 06/08/23, 06/20/23 and 06/27/23. LPA also observed LAPD Missing Person report dated 06/07/23 and hospital discharge paperwork dated 06/26/23 which did not reveal that C1 was treated for a gash on their back or anywhere else on their body. All incident reports reviewed list C1's family member and contact phone number. Interviews with 6 out of 7 clients revealed that facility maintains documentation and when necessary family or responsible parties are notified of incidents and they do not have any concerns regarding facility's documentation or anything else. 1 out of 7 clients did not want to answer the question and terminated interview.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230712142353
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WINDSOR HALL CARE HOME INC.
FACILITY NUMBER: 197602798
VISIT DATE: 03/05/2024
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
26
27
28
29
30
31
32
For allegation, Lack of care and supervision resulted in resident being physically assaulted by another client causing significant injuries, it is alleged that on 06/06/23 C1 was pushed by two unknown clients from behind causing C1 to fall and sustain a large gash on their back and C1 was hospitalized as a result. Interviews conducted with facility staff revealed that C1 was not pushed by two clients which caused C1 to sustain a large gash on their back. Staff stated that C1 was hospitalized on 06/06/23 due to not feeling well and subsequently falling. Staff denied that C1 sustained a large gash on their back due to the fall and stated that clients did not cause C1 to fall. Staff stated that C1 was discharged on 06/08/23 from the hospital and the hospital did not notify the facility of C1's discharge and that due to that C1 was missing until 06/20/23 when he subsequently returned to the facility. Staff did file a missing person report with LAPD. Staff stated that if C1 sustained any injuries it could have happened when C1 was missing. Staff stated that C1 is still a client of the facility. Staff denied the allegation of Neglect/Lack of Supervision and stated that there are enough staff on schedule throughout the day and during the night to properly supervise all clients in care as well as to ensure that all clients are safe at all times. Interviews conducted with 6 out of 7 clients revealed that they feel safe at the facility, staff intervene immediately if there are ever any altercations between clients and that staff provide adequate care and supervision at all times. They stated that they think the facility has sufficient staff at all times, their needs are being met and they do not have any concerns. 1 out of 7 clients did not want to answer the question and terminated interview. LPA review of incident report dated 06/06/23 did not reveal that C1 was pushed by two clients or that C1 sustained a gash on their back due to the fall or the altercation. LPA review of staff roster revealed that the facility has adequate staff on schedule.

During the visits conducted on 07/13/23 and 03/05/24, LPA observed clients in their rooms sleeping, in the common area watching television and also sitting outside in the patio area. LPA did not observe anything of concern. Based on statements gathered from interviews conducted with staff, clients, LPA record review and observations, there was not enough supportive evidence to concur with the reported allegations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Administrator Honeylet Urrea.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3