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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804011
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:35:48 PM

Document Has Been Signed on 03/18/2022 02:35 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 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: 1DATE:
03/18/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Caregiver, Cheryl AlconesTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct a Post Licensing inspection and met with caregiver, Cheryl Alcones. Licensee, Arthur Alcones was available by phone and gave permission for caregiver to sign report. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, caregiver took LPA's temperature and asking standard Covid screening questions. LPA noted that the temperature on the thermometer was very low compared to LPA's normal temperature. Review of visitor log revealed that all visitors appeared to have low temperatures. LPA suggested to caregiver that the battery may need to be changed or the thermometer may need to be replaced. Per conversation with caregiver, they verbally confirm with visitors that they are vaccinated but have not requested the actual vaccination card. LPA instructed caregiver that visitors must provide proof of vaccination per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility and observed the following: Facility has some COVID-19 posters in the hallway and hand washing signs in bathrooms but there are no postings on the front door or in the entryway. LPA suggests adding posters to more central areas of the facility Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had a mask on during this visit. Commonly touched surfaces are disinfected once per day . Facility maintains documentation of resident daily temperatures but per caregiver, they take staff's temperatures at the beginning of their shift but it is not being documented. LPA instructed staff to start documenting staff temperatures as well.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms. Staff have completed PPE training and have been N95 fit tested.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSOR GOLDEN LIVING
FACILITY NUMBER: 496804011
VISIT DATE: 03/18/2022
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Continued from LIC809C

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including masks, gloves, face shields and hand sanitizer. Additional PPE should be stored at the facility. Facility maintains a 30 day supply of medication.

Licensee has put in a fence to enclose the entire yard to decrease the risk to a resident who may have wandering behavior. Licensee will submit an update to their Dementia Care Plan.



Licensee and LPA discussed their Emergency Disaster Plan.

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

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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