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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208930
Report Date: 11/21/2024
Date Signed: 11/21/2024 05:11:07 PM

Document Has Been Signed on 11/21/2024 05:11 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:WINDHAM, THEFACILITY NUMBER:
107208930
ADMINISTRATOR/
DIRECTOR:		EARLEY, JOHNFACILITY TYPE:
740
ADDRESS:1100 E SPRUCE AVETELEPHONE:
(559) 449-8070
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 88CENSUS: 81DATE:
11/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:40 PM
MET WITH:Licensee - John EarlyTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 11/21/2024, Licensing Program Analyst (LPA) M Vega conducted an unannounced case management at 1540 hours. LPA met with Health and Wellness Director Nancy Pultz. Licensee John Earley was contacted by phone and arrived a short moment after. The purpose of this visit is to deliver the finding of review completed by the Department.

LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

On 08/16/2024, the Department received a complaint and conducted the investigation. During the course of investigation, it was discovered that staff failed to supervise resident (R1) while in care. On 07/22/2024, R1 was found deceased in an empty field adjacent to the facility. The last time staff saw R1 was at approximately 1600 hours. Staff failed to notify anyone until approximately 2115 hours. According to Physician’s Report, R1 was diagnosed with Dementia. R1 was not able to leave the facility without staff escort or supervision due to R1’s cognitive impairment. Staff admitted they never supervised R1 outside of the facility.

Based on the review conducted by the Department and information gathered, the following deficiency was cited on LIC 809-D per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8. An immediate civil penalty of $500.00 was issued and a copy of the LIC 421IM was given to Licensee John Earley. At the time of the case management on 11/21/2024, licensee was informed that a future civil penalty may apply based on Health and Safety Code § 1569.49.

An exit interview was conducted, and a copy of this report dated 11/21/2024, along with licensee. Appeal Rights (LIC 9058) was provided to Licensee John Earley whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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Document Has Been Signed on 11/21/2024 05:11 PM - It Cannot Be Edited


Created By: Martin Vega On 11/21/2024 at 04:31 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: WINDHAM, THE
FACILITY NUMBER: 107208930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
87705(b)(2)

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87705 CARE OF PERSONS WITH DEMENTIA 87705 (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1)
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Licensee stated that staff training on care of persons with dementia will be conducted on 11/21/2024. Licensee agrees to develop a written plan of correction (POC) describing in writing how facility shall ensure compliance with
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Procedures for notifying the resident's physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident's behavior or condition changes. (2) Safety measures to address behaviors such as wandering,... materials.
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CCR 87705 and how similar incident related to violation will be prevented in the future for health and safety of residents. POC shall be received in licensing office by fax and/or mail by due date. Failure to meet POC due date may result in a civil penalty of $100 or more per day.

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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:Brenda Chan
LICENSING EVALUATOR NAME:Martin Vega
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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