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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802025
Report Date: 05/30/2024
Date Signed: 05/30/2024 05:34:29 PM

Document Has Been Signed on 05/30/2024 05:34 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:BROOKDALE WINDSORFACILITY NUMBER:
496802025
ADMINISTRATOR/
DIRECTOR:		KINNEY, JEANNETTEFACILITY TYPE:
740
ADDRESS:907 ADELE DRTELEPHONE:
(707) 837-8785
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 80CENSUS: 57DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Tina Wolden, Health and Wellness DirectorTIME VISIT/
INSPECTION COMPLETED:
05:48 PM
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Licensing Program Analysts (LPA) Christi Coppo and Jacqueline Macias arrived unannounced to conduct a required Annual inspection and was greeted by Staff. Administrator Jeannette Kinney was not available, but LPAs contacted and Admin indicated Tina Worden, Health and Wellness Director (HWD) has signing permissions. HWD arrived later. Facility contact information was reviewed.

At approximately 10:15am LPAs and HWD toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner. LPAs observed cereal bag not properly sealed; open and exposed. English muffins were not properly stored in the bag; open and exposed. Ice cream tubs were not covered but stored in a covered ice cream freezer. White granular substance was stored in a plastic container with plastic “cling” wrap but without proper lid. Avocados were stored inside the refrigerator without being placed in a Ziploc or plastic wrap. Jello cups were stored on a tray but open and exposed without plastic wrap covering the cups. Container underneath the garbage disposal/sink area had food waste.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 116.9 F in community bathroom downstairs, 117.1 F in room #30, 119.1 F in room #68, 117.2 F in room #40, which are all within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 10/30/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational as indicated per Fire Safety Supply's Inspection, Testing, and Maintenance Report dated 12/27/23. Facility’s last quarterly disaster drills were conducted on 5/2/2024.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: BROOKDALE WINDSOR
FACILITY NUMBER: 496802025
VISIT DATE: 05/30/2024
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Continued from 809...

At approximately 12:00pm LPAs conducted a review of 5 resident records. All required documentation present.



At approximately 1:00pm LPAs conducted review of 5 staff records. S1, S2, S3, S4, and S5 have no 1st AId/CPR, Health Screen, or Training records on file (respective deficiencies cited, see 809Ds).

At approximately 3:00pm LPAs accompanied Med Tech on afternoon med pass. LPAs observed Med Tech to live pour medications and medication cart remained locked when out of Med Tech sight. Medication is centrally stored in a locked cabinet. No deficiencies

Jeannette Kinney Administrator Certificate 7016943740 expires 8/12/2024. All fees are current.



LPA and HWD discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

On 2/26/2024 CCL received an Incident Report indicating a resident R1 eloped on 2/22/2024. At approximately 5:20pm it was discovered that R1 was not accounted for in the dining services area. Per review of the Resident's Physician's Report, resident not able to leave facility unless escorted by family. The facility initiated elopement protocol. At 7:10pm the Health and Wellness Director received a call from EMS indicating they had found R1 and transported them to the hospital for safety. R1 was checked at the ER for injury, infection, and R1 returned to the facility at 9:30pm. Per incident report facility implemented 1:1 caregiver with R1 for safety. Resident then moved to a different facility and no longer resides at facility.

On 5/3/2024 CCL received an Incident Report indicating there was a medication error as pertains to resident R2 on 4/16/2024. At approximately 7:30pm on 4/16/24 staff on duty gave R2 a dose of Nitrofurantoin and one dose of Phenazophyridine in error. These two medications were received and entered under the wrong resident's profile. The error was discovered during the shift change. Nurse immediately reported the error.

Continued on 809C(2)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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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: BROOKDALE WINDSOR
FACILITY NUMBER: 496802025
VISIT DATE: 05/30/2024
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Continued from 809C...

Per Incident Report, resident did not have any adverse reaction or side effects from medication error. PCP notified by phone and responded that medical treatment was not necessary. R2 was placed on monitoring and increased safety checks for 72 hours. Per Incident Report, staff that made the error received formal counseling and training with Health and Wellness Director (HWD).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with HWD. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with HWD and a copy of this report was given

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/30/2024 05:34 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/30/2024 at 04:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE WINDSOR
FACILITY NUMBER: 496802025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and HWD observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have current First Aid/CPR, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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2
3
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Facility to submit plan to have S1, S2, S3, S4, and S5 obtain First Aid/CPR certification by 5/31/2024. Certification to be completed for all identified staff no later than 6/13/2024.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on incident report received on 5/3/2024, the licensee did not comply with the section cited above in that R2 received medication not prescribed to them, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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2
3
4
Facility to provide CCL with training log showing training conducted with staff on medication management as indicated on Incident Report by Plan of Correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


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Page: 4 of 9
Document Has Been Signed on 05/30/2024 05:34 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/30/2024 at 04:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE WINDSOR
FACILITY NUMBER: 496802025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and HWD observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have Heath Screens, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Facility to submit pictures of completed Health Screens for S1, S2, S3, S4, and S5 plan of correction due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/30/2024 05:34 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/30/2024 at 04:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE WINDSOR
FACILITY NUMBER: 496802025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on on Incident Report received on 2/26/2024, the licensee did not comply with the section cited above in that R1 had an elopement, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Facility to train staff on elopement procedures and preventative measures, and submit training log to CCL by POC date. Training log to include name of trainer, name of course, staff attendees, and hours completed.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/30/2024 05:34 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/30/2024 at 04:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE WINDSOR
FACILITY NUMBER: 496802025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have Training records available, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
1
2
3
4
Facility to submit pictures of completed training logs for S1, S2, S3, S4, and S5 by plan of correction due date. Training logs to contain name of trainer, name of course, duration of course in hours, dated completed and employee attendee.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


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