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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802016
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:15:04 PM

Document Has Been Signed on 05/04/2023 03:15 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
SANTA ROSA RO, 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: 3DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, John SchoonoverTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, John Schoonover.

LPA initiated a tour of the facility around 12:40pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathroom used by residents measured at 107 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was locked. Knives are locked in kitchen drawer. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the garage.

Fire extinguisher is fully charged and is due for servicing as of 4/2023. Administrator will replace Fire Extinguisher. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection.

Three staff files and three resident files were reviewed. Administrator Certificate for Administrator, John Schoonover 6030504740 expired 2/2/2023. Administrator provided proof that they have sent in the documents for recertification to the Administrator Certification Unit. Medications and medication records were reviewed.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSOR HOUSE II
FACILITY NUMBER: 496802016
VISIT DATE: 05/04/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 6/04/2023:


LIC 500 Personnel Summary
LIC9020 Register of Facility Clients/Residents
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

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

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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