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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802016
Report Date: 06/15/2021
Date Signed: 06/15/2021 02:46:28 PM

Document Has Been Signed on 06/15/2021 02:46 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:WINDSOR HOUSE IIFACILITY NUMBER:
496802016
ADMINISTRATOR:JOHN SCHOONOVERFACILITY TYPE:
740
ADDRESS:113 LEAFY GLADE PLACETELEPHONE:
(707) 838-9602
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 4DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Administrator, John SchoonoverTIME COMPLETED:
03:01 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Administrator, John Schoonover.

Upon arrival, LPA was screened by Administrator and screening was documented. LPA was asked to sanitize hands prior to walking into the facility. LPA conducted a walk-through of the facility with the Administrator and observed Covid-19 posters throughout that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout the facility and infection control has been discussed with residents and staff. Residents are encouraged to wear masks when outside of their rooms and staff are required to wear them while in the facility. Observed staff had masks on during this visit.
Commonly touched surfaces are disinfected on each shift.
Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPA and Administrator discussed resident activities and visitation. Facility has a designated visitation area. Caregivers have completed PPE training and Administrator is currently looking at options for N-95 fit testing.
Facility has submitted and received approval for their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. Facility maintains a 30 day supply of medication.

Facility has a 100% vaccination rate of staff and residents so is not required to surveillance test.

LPA confirmed that Administrator has reviewed PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, ect.



Administrator and LPA discussed their Emergency Disaster Plan. LPA requested that facility add an additional temporary shelter location.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2021
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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