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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802016
Report Date: 04/15/2022
Date Signed: 04/15/2022 01:25:32 PM

Document Has Been Signed on 04/15/2022 01:25 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: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: 5DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Administrator, John SchoonoverTIME COMPLETED:
01:35 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. This inspection is focused on the infection control procedures of this facility.

Upon arrival, LPA was screened by staff and screening was documented. 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.

LPA and Administrator discussed resident activities and visitation. Facility has a designated visitation area. Caregivers have completed PPE training and Administrator confirmed that staff are N-95 fit tested.

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 is currently following staff vaccination guidance.

LPA confirmed that Administrator is receiving Provider Information Notices (PINs) sent by the department.



Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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: WINDSOR HOUSE II
FACILITY NUMBER: 496802016
VISIT DATE: 04/15/2022
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Continued from LIC809

Administrator provided the LIC9020 Registry of Residents. Licensee/Administrator to submit updates of the following documents by June 30, 2022:

LIC 610 Emergency Disaster Plan
Copy of current Administrator's Certificate
Infection Control Plan per PIN 22-13

Administrator and LPA discussed their Emergency Disaster Plan and provided guidance regarding the Infection Control Plan.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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