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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804011
Report Date: 08/30/2022
Date Signed: 08/30/2022 04:48:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220706100129
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: 4DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Licensee, Arthur AlconesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident incontinence care needs are not being met
Facility is not providing activities
Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Licensee, Arthur Alcones.

Resident incontinence care needs are not being met – Complaint alleges that resident, R1 is left in wet incontinence briefs and on at least one occasion, there was enough liquid to drip onto the floor. Complaint goes on to allege that staff used disinfecting wipes instead of incontinence wipes causing resident to complain of burning and that facility refuses to allow for a bidet to aid the resident in providing for some of their own toileting needs. LPA was provided a photo of a person identified as R1 sitting on a chair with an incontinence brief on and a pad underneath them and a puddle below them. Per interviews, staff did mistakenly use a disinfectant wipe but when resident complained of burning, the mistake was realized, and the wipes were not used again.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 21-AS-20220706100129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/30/2022
NARRATIVE
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Continued from LIC9099

Personal Rights – Complaint alleges that R1 does not feel comfortable coming into common areas of the facility because of another resident’s behavior. During a visit, LPA heard a resident, R2 yelling. Interviews also supported that R2 yells and interview confirmed that at least one resident has been frightened by R2’s behavior. Staff interview indicated that R2 curses at staff but not other residents. Facility recently reported that R2 was “verbally and physically aggressive” resulting in 911 being called.

Facility is not providing activities – Complaint alleges that facility does not provide activities. Per staff interview, they attempt to engage residents in activities like walking around the facility, but residents refuse. Other interviews indicate that staff do not regularly offer walks or other activities and walks are sporadic because two staff are required to ensure supervision and the facility does not always have two staff on shift. Per interview, residents engage in individual activities, like watching tv, but not group activities, like having a musician come in.

The allegation, that Resident incontinence care needs are not being met, Facility is not providing activities
and Personal Rights is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220706100129

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: 4DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Licensee, Arthur AlconesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident's medication management needs are not being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Licensee, Arthur Alcones.

Resident's medication management needs are not being met – Complaint alleges that resident, R1 is to receive insulin 30 minutes before a meal but on at least two occasions was given incorrect dosage. Complaint alleges that R1 is to receive insulin prior to each meal and was given insulin around 11:30am for lunch but when lunch was delayed, R1 was given a second dose before their actual lunch. Photo provided shows resident’s blood sugar monitor showing that blood sugar was checked twice between 11:30am and 1:45pm. Review of resident’s schedule from the facility indicates that resident has their blood sugar checked at 11:30am and receives insulin. The next check and insulin is scheduled for 4:30pm. LPA was unable to confirm that resident was given insulin as alleged in the complaint.

A finding that the complaint allegation Resident's medication management needs are not being met was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220706100129

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: 4DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Licensee, Arthur AlconesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Level Of Care - Resident not assessed for proper level of care
Licensee is not providing personal accommodations per regulation
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Licensee, Arthur Alcones.

Level-Of-Care - Resident not assessed for proper level of care – Complaint alleges that resident has not had any changes in care since moving in but facility has raised the monthly fee due to a change of level of care. Review of the facility’s level of care rates, the resident was admitted at Level 1 which indicates resident needs minimal assistance and is ambulatory or walks with a walker independently and can transfer independently with minimum assistance. The Physician’s Report dated 3/22/2022 indicates that resident needs standby assistance with bathing, toileting and transferring but can feed, dress and groom themselves. Resident was identified in the report as non-ambulatory and indicated the resident used a walker due to leg weakness. Preplacement appraisal indicates that resident is not able to walk without assistance and uses a walker. It indicates that resident does not use a wheelchair.

Continued on LIC9099
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20220706100129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/30/2022
NARRATIVE
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Continued from LIC9099

Preplacement appraisal indicates that resident needs standby assistance when using the walker and needs help moving about the facility. Resident also needs assistance with incontinence care, needs staff to hand them their clothes and that resident sleeps through the night. The reappraisal dated 7/1/2022 indicates that noted resident is wheelchair bound and rarely uses a walker due to increased weakness and needs moderate to maximum assistance with bathing, toileting and dressing. Level 2 of the facility’s level of care rates indicates a resident who needs moderate to maximum assistance with Activities of Daily Living such as bathing, toileting, dressing, is a fall risk or needs 1-2 person transferring and/or needs assistance with incontinence care. Evidence indicates that resident’s needs changed after move-in.

Licensee is not providing personal accommodations per regulation – Complaint alleges that facility did not provide a chair in the resident’s room. Additional interview and a picture revealed that facility did provide a chair.

This agency has investigated the complaint alleging Level Of Care - Resident not assessed for proper level of care and Licensee is not providing personal accommodations per regulation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 21-AS-20220706100129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2022
Section Cited
CCR
87411(a)
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87411 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. This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure resident’s incontinence was managed appropriately.
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Licensee agrees to conduct an in-service with staff to ensure the proper incontinence products are used and that residents are checked as often as needed to manage their incontinence. Proof of inservice training to be submitted to LPA no later that 8/31/2022.
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This is an immediate risk to personal rights.
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Type A
08/31/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure
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Licensee agrees to conduct an in-service with staff regarding regulation 87468.1 to ensure resident's personal rights. Proof of inservice training to be submitted to LPA no later that 8/31/2022.
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resident’s personal rights. This is an immediate risk to personal rights.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20220706100129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2022
Section Cited
CCR
87219(a)
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87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure residents are provided adequate activities.
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Licensee agrees to provide a written plan on how they will ensure that they have enough staff to engage residents in activities by POC due date, 9/5/2022.
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This is a potential risk to health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7