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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804011
Report Date: 08/30/2022
Date Signed: 08/30/2022 04:58:58 PM

Document Has Been Signed on 08/30/2022 04:58 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: 4DATE:
08/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Licensee, Arthur AlconesTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst Willis arrived unannounced to conduct a Case Management inspection and met with Licensee, Arthur Alcones.

During investigation LPA discovered deficiencies that were not part of the complaint.

Interviews revealed that the Licensee verbally communicated care changes to the responsible party of a resident in June 2022 but there is a discrepancy of whether a rate change was discussed. A letter dated 6/22/2022 from the Licensee notified the responsible party of the rate change but per interview, the letter was not provided to the responsible party until 7/1/2022. Per interview, the appraisal dated 7/1/2022 was included with the letter. The responsible party had previously paid the lower care rate for July 2022 so the difference was due. A second and third notice followed on 7/7/2022 and 7/8/2022. The responsible party was then given a 30-day notice of eviction dated 7/10/2022 due to non-payment of fees and indicating that the facility was no longer able to meet the care needs. An updated appraisal was not provided supporting that the facility was no longer able to meet the care needs. Per Licensee, they provided the letter to the responsible party on 7/11/2022. Per interviews, on 7/10/2022, the responsible party attempted to give payment to facility staff who refused the payment and instructed the responsible party to mail the check to the address on the Admission Agreement despite the facility accepting payment in this way previously. Per Admission Agreement, payment can be made by sending a check to the listed mailing address however, it also allows for individuals to submit payment at the facility. The responsible party provided payment to the address indicated on the Admission Agreement but was not notified until July 27, 2022 that the eviction had been rescinded despite being notified of their obligation to notify the resident and their responsible party by this LPA multiple times.

Continued on LIC809C
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.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 08/30/2022
NARRATIVE
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Continued from LIC809

During investigation LPA conducted a review of facility’s current Admission Agreement which was part of the facility’s approved program design and was being used by the facility. Review revealed that certain language does not meet Title 22 regulations. Because this language was not previously identified by the Department, Licensee will not be cited but will be required to submit a revised Admission Agreement for further review and approval to the CCL SRRO by 9/16/2022.

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
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/30/2022 04:58 PM - It Cannot Be Edited


Created By: Victoria Willis On 08/30/2022 at 03:12 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: 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
09/02/2022
Section Cited
CCR
87468.1(a)(9)

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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: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by: Based on interviews, the
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Licensee agrees to submit a policy regarding how they will effectively communicate with residents and their responsible parties per regulation by POC due date, 9/2/2022.
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Licensee did not ensure responsible party was adequately communicated with regarding the level of care change and status of the eviction. This is an immediate risk to personal rights 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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