<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804011
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:00:20 PM

Document Has Been Signed on 12/22/2021 01:00 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 GOLDEN LIVINGFACILITY NUMBER:
496804011
ADMINISTRATOR:ALCONES, ARTHUR O.FACILITY TYPE:
740
ADDRESS:65 BLUEBIRD DRIVETELEPHONE:
(707) 953-2161
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 0DATE:
12/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Applicant, Arthur AlconesTIME COMPLETED:
01:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Victoria Willis and Caitlynn Felias arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Arthur Alcones.

Upon arrival, LPAs were screened for Covid-19 symptoms and had their temperatures checked. Facility is a one story residence with four client bedrooms, two single rooms and two shared rooms, three bathrooms and common areas. Facility plans to eventually have a capacity of 14 and will submit a change of capacity at that time. Resident rooms are furnished with a bed, chair and bedside table. Two bedrooms do not have a lamp and three bedrooms do not have dressers. Bathroom showers have bath mats and grab bars. Water temperature in bathroom read at 122 degrees F which is over the regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked pantry in the kitchen that may be used for centrally stored medications and files. Cleaning supplies and other items, like knives, will also be locked in pantry. Perishable and non-perishable foods observed per regulation. Facility backyard has an area for visiting and activities. Facility does not currently have a fence around the entire perimeter of the yard. At this time, facility is choosing to not admit residents with wandering behavior. Applicant has agreed to update their Plan of Operation to remove language regarding advertising for dementia and add policy regarding not admitting or retaining residents with wandering behavior.

Facility received an approved fire clearance dated October 26, 2021 that allows for 4 non-ambulatory clients and 2 bedridden. Hardwired smoke alarms and Carbon Monoxide detector were tested and operational. Facility has emergency lighting in hallways. LPAs confirmed that contents of the facility First Aid Kit were sufficient.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 GOLDEN LIVING
FACILITY NUMBER: 496804011
VISIT DATE: 12/22/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809

LPAs confirmed that Applicant is familiar with Guardian and has read the most recent Provider Information Notices (PINs) that the department sent out regarding Covid-19 vaccinations and visitation.

Component III is waived due to Applicant being a current Licensee.

The following items are needed in order to move forward with licensure:

Noted updates to Plan of Operation
Applicant to turn down water heater and submit three days of temperatures within regulation to LPAs
Receipt showing that Applicant has obtained copies of Rights to Resident Councils and Family Councils for posting

Once above items are received, LPAs will notify Application Unit so application process may proceed.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2