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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804011
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:45:17 PM

Document Has Been Signed on 10/19/2022 12:45 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: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: 5DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Licensee, Arthur AlconesTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by a caregiver. Licensee, Arthur Alcones arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff for Covid-19. LPA initiated a walk-through of the facility around 11:00am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected after meals, in the morning and in the evening. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of PPE and have been N95 fit tested. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced September 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: WINDSOR GOLDEN LIVING
FACILITY NUMBER: 496804011
VISIT DATE: 10/19/2022
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Continued from LIC809C

Licensee and LPA discussed their Emergency Disaster Plan and their Infection Control Plan. Licensee provided LPA with their Liability Insurance inspection.



Licensee/Administrator to submit updates of the following documents by 11/19/2022:

LIC 308 Designated Administrator - If applicable
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update)
LIC 9020 Register of Facility Client’s/Resident’s

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

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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