336403366-8-10-2025-18-AS-RORN-DKWLMU-20250826085316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336403366
Report Date: 08/10/2025
Date Signed: 08/10/2025 05:24:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2024 and conducted by Evaluator Mayra Cota

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240904075959

FACILITY NAME:	WINDSOR COURT ASSISTED LIVING		FACILITY NUMBER:	336403366
ADMINISTRATOR:	AURELIEN FRUIT		FACILITY TYPE:	740
ADDRESS:	201 S. SUNRISE WAY		TELEPHONE:	(760) 327-8351
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	130	CENSUS: 130	DATE:	08/10/2025
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Bobbie Rodriguez, Director of Memory Care Unit		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Facility took resident's medication from the room without the resident's permission.
Facility did not order refill for the resident's prescription medications on time.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Mayra Cota and Blanca Gonzalez conducted another subsequent visit to investigate the allegations listed above. LPAs met with Bobbie Rodriguez, Director of Memory Care Unit and the reason for the visit was explained. Initial 10 day visit was conducted on 1/6/25 by LPA Jeon which followed by subsequent visits from LPAs Cota and Gonzalez on 8/9/25 and 8/10/25.

During initial 10-day visit, LPA Jeon, conducted tour of the facility, conducted record review, obtained requested copies of pertinent documentation, and interviewed staff and residents.

During subsequent visit conducted on 8/9/25, LPAs obtained copies of staff and resident rosters, toured the facility and conducted interviews with Resident 1 (R1) and Resident 7 - Resident 10 (R7-R10), and Staff 2 - Staff 6 (S2-S6). LPAs also obtained copies of R1's Physician Report and Medication Administation Record (MAR) for May - August 2025.

During today’s visit, LPAs toured common areas of the facility, and delivered findings.

The investigation revealed the following: ***Continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240904075959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WINDSOR COURT ASSISTED LIVING	FACILITY NUMBER: 336403366
	VISIT DATE: 08/10/2025

NARRATIVE

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Regarding: Facility took resident's medication from the room without the resident's permission.

It is alleged that medication was taken by facility staff from resident's room without their permission. It is also alleged that resident has permission from physician to handle their own medication.

Interviews with (6) out of (6) staff, deny the allegation. Interviews with S1-S6 indicated, staff do not take medication from resident rooms without permission. Staff indicated, they help residents manage medication when there is a physician's order which states resident needs assistance with medication administration and that resident is in agreement via signed release form. Interview with S2 revealed, facility has been managing R1's medication because R1 has agreed to due to R1 mismanaging their medication in the past. Interviews with S2-S4 further indicated, R1 receives their medication daily from med-tech staff who order and store R1's medication in the medication cart and document medication taken accordingly on MAR. Interviews with S5 and S6 indicated, R1 willingly takes medication provided by med-tech staff during medication pass and has never complained about med-techs assisting with managing R1's medication.
Interviews with R2-R10 also deny the allegation. Residents stated, staff do not enter rooms to take medication belonging to residents. Additional interview conducted with R1 during visit on 8/9/25 indicated, facility manages their medication which they are in agreement with. R1 stated, they get their medication on time every day from staff at the facility. Record review indicated, Individual Service Plan from 3/11/24 - 9/11/2024 stated, "resident will require medication to be administered by RCFE staff as prescribed by physician." Most current physician report on file for R1 dated, 4/29/25 also indicates, R1 is not able to administer their own prescribed medication and thus, medication needs to be given to them by staff. Review of MAR from May - August, 2025 indicate, facility continues to administer medication to resident and is documented accordingly on MAR. Interviews with staff, residents and record review do not corroborate the allegation.

****Continues on LIC 9099-C page 2

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240904075959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WINDSOR COURT ASSISTED LIVING	FACILITY NUMBER: 336403366
	VISIT DATE: 08/10/2025

NARRATIVE

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Regarding: Facility did not order refill for the resident's prescription medications on time.

It is alleged that staff forgot to order medication refill for resident for about 2 months and it was the facility's responsibility to order the refill.

Staff deny the allegation. Interviews with (6) out of (6) staff indicated, resident's medication is ordered on time. Interviews with R3-R4 revealed, there has not been a (2) month lapse in medication administration for R1. R3-R4 indicated, medication is ordered on time and given to residents correctly without interruptions. R3 stated, if R1 would have had such a long interruption in taking their medication, it would have been detrimental for their health. R3 further stated, "Residents need their medication to be administered without interruptions in order to live." Interviews with S5-S6 indicated, R1 receives their medication, daily, on time and without interruptions. Interviews with (9) out of (10) residents indicated, their medication refills are always ordered by the facility on time and there are no interruptions on taking their medication. Additional interview conducted on 8/9/25 indicated, R1 has been receiving her medication from med-tech staff since their initial admission to the facility. R1 also stated, they receive their medication daily and on time. Record review indicated, MAR from May - August 2025 reflect medication has been administered correctly to R1 without interruptions by facility staff. Staff and resident interviews and record review, does not corroborate the allegation.

.Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, with Bobbie Rodriguez, Director of Memory Care Unit and a copy of this report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2025

LIC9099 (FAS) - (06/04)

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