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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804011
Report Date: 12/09/2024
Date Signed: 12/09/2024 04:48:40 PM

Document Has Been Signed on 12/09/2024 04:48 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/
DIRECTOR:
ALCONES, ARTHUR O.FACILITY TYPE:
740
ADDRESS:65 BLUEBIRD DRIVETELEPHONE:
(707) 953-2161
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Arthur Alcones-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Alviso arrived to conduct a required - 1 Year inspection, on 12/9/24 at approximately 9:55am. LPA was greeted by the caregivers that were on duty. Lead Caregiver Liza contacted the Administrator Arthur Alcones regarding the LPA's arrival to the facility. Administrator arrived within the hour to meet with the LPA.

Facility has a required emergency disaster plan. Facility has a required infection control plan. Facility has an approved hospice waiver for three (3) residents only. Facility has an approved dementia plan of operation.

Facility has a fire clearance for six (6) nonambulatory, of which two (2) may be bedridden. Only the four (4) front rooms can be used for bedridden. Facility has five (5) residents in care. Per record reviews, last emergency disaster drills were conducted on 10/22/24 and 9/3/24; LPA discussed the requirement of ensuring that one of the drills done quarterly is an evacuation drill. Administrator stated their understanding of the above and has an evacuation drill planned this December 2024.

LPA toured the facility. Hot water was checked at 120. degrees Fahrenheit, which is within regulation. Administrator agreed to ensure the hot water is not above 120. degrees Fahrenheit and no lower than 105. degrees Fahrenheit. All fire extinguishers, two (2), were serviced and tagged as required. All smoke alarms were marked as working appropriately per inspection. All exit doors had auditory alarms on them. Food supply was sufficient. All medications were stored appropriately and locked up per regulations. All cleaners/disinfectants were locked up and inaccessible to residents in care. Sufficient supply of linens, paper products, furnishings, hygiene products, and personal protective equipment (PPE) for use by the facility. The facility was at a comfortable temperature. There was sufficient lighting for residents in all common areas, hallways, bathrooms, and resident rooms.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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: 12/09/2024
NARRATIVE
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LPA is requesting the following documents be updated and submitted by 1/9/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

LPA reviewed five (5) resident files, including reviewing logs and medication storage. All files were complete, and all medications were stored appropriately.
LPA reviewed four (4) staff files, including training. All staff had criminal record clearance as required. Staff had required training. Three (3) out of four (4) staff lacked first aid and cpr certification as required.

The following deficiencies were observed during the inspection and will be cited:

Per record reviews, three (3) out of four (4) staff lacked first aid as required. S3 is a direct caregiver, and is a staff that has been on their own working with residents in care. LPA observed this upon arriving to the facility today, 12/9/24. This deficiency will be cited, 87411(c )(1) Personnel Requirements – General- All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiency (s) by due date (s), may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with the Administrator Arthur Alcones. Appeal Rights Provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2024 04:48 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/09/2024 at 04:24 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: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
87411(c )(1) Personnel Requirements – General- All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per record reviews, three (3) out of four (4) staff lacked first aid as required. S3 is a direct caregiver, and is a staff that has been on their own working with residents in care. LPA observed this upon arriving to the facility today, 12/9/24., the licensee did not comply with the section cited above in [1] out of [4] staff, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Licensee/Administrator to ensure S3 obtains first aid certification, as well as cpr, as required by regulation. Ensure that S3 is not left alone with residents in care until receiving recertification as requested above. Submit copy of first aid and cpr certification of S3 by POC due date of 12/10/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


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