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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802016
Report Date: 05/14/2024
Date Signed: 05/14/2024 10:39:16 AM

Document Has Been Signed on 05/14/2024 10:39 AM - 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/
DIRECTOR:
JOHN SCHOONOVERFACILITY TYPE:
740
ADDRESS:113 LEAFY GLADE PLACETELEPHONE:
(707) 838-9602
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 3DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:John Schoonover (Administrator)TIME VISIT/
INSPECTION COMPLETED:
10:54 AM
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Licensing Program Analyst, (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator, John Schoonover. Required postings were observed.

LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathrooms measured at 116.2 and 111.6 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet in laundry room containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was bought April 22, 2024 and it was fully charged. Smoke detectors located throughout the facility were tested and operational. Carbon Monoxide Detector was tested and operational. Last disaster drill conducted on April 25, 2024.

File review was initiated at 9:30 am. Two staff files and three resident files were reviewed. Residents have current medical assessments and care plans. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, John Schoonover 6030504740 expires 2/2/2025. Medications and medication records were reviewed. Training records were reviewed.

Administrator to submit updates of the following documents by 5/24/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E if there are any changes) and copy of liability insurance.

No deficiencies cited during this inspection. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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