Inspection Reports for Windsor Court Assisted Living – Palm Springs
201 S Sunrise Way, Palm Springs, CA 92262, United States, CA, 92262
Back to Facility ProfileInspection Report Summary
Most inspections at this facility found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. The most recent report from September 18, 2025, cited one minor deficiency related to eviction procedures, where staff issued an eviction notice without prior approval from the licensing agency. More serious issues in past reports included substantiated findings of resident abandonment in June 2025 and violations of residents’ personal rights due to unauthorized video recording of residents, also in June 2025. Other notable deficiencies involved failure to provide proper notice of rent increases and lapses in staff criminal record clearance, but these were isolated incidents. Overall, the facility appears to have addressed many prior concerns, with no deficiencies noted in the most recent annual inspection and several complaint investigations showing improvement or unsubstantiated claims.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
100% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 130
Capacity: 130
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
Licensing Program Analyst Seo Jeon made an unannounced Case Management visit regarding an eviction notice received by the Department on September 17, 2025.
Findings
No health and safety concerns were found during the visit; however, a citation was issued because staff served an eviction notice to a resident's responsible person without prior approval from the Department.
Deficiencies (1)
Eviction Procedures violation: The licensee issued an eviction notice without obtaining prior written approval from the licensing agency, posing potential health, safety, or personal rights risk to the resident.
Report Facts
Citation count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carminia Meza | Director of Nursing | Met with Licensing Program Analyst during the visit |
| Seo Jeon | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Aurelien Fruit | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Date: Aug 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff were not providing adequate meal service to residents, including serving expired food and causing residents to become sick.
Complaint Details
The complaint alleged that on or around 08/16/2024, residents were served dinner that caused sickness and that expired food was being served. The investigation included observations of food storage and meal service, and interviews with staff and residents. The complaint was found to be unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found that the facility provided adequate food service with fresh, non-expired food. Interviews with staff and residents largely denied the allegations, and there was insufficient evidence to substantiate the complaint. The allegation was determined to be unsubstantiated.
Report Facts
Staff interviewed: 10
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Blanca Gonzalez | Evaluator / Licensing Program Analyst | Conducted the complaint investigation visit |
| Mayra Cota | Licensing Program Analyst | Conducted subsequent complaint visit |
| Bobbie Rodriguez | Director of Memory Care | Met with LPAs during the investigation |
| Aurelien Fruit | Administrator | Facility administrator named in the report |
| Wei Siew Ho | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Date: Aug 10, 2025
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations that staff did not keep resident's room free from pests and did not treat residents with dignity and respect.
Complaint Details
The complaint involved allegations of pest presence in resident rooms and staff disrespect towards residents. The investigation included facility tours, interviews with staff and residents, and document reviews. The complaint was found to be unsubstantiated.
Findings
The investigation found no evidence of pests in resident rooms or common areas, and interviews with staff and residents did not corroborate allegations of disrespectful treatment. The allegations were determined to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Residents interviewed: 10
Staff interviewed: 9
Resident rooms toured: 6
Facility capacity: 130
Facility census: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Blanca Gonzalez | Licensing Program Analyst | Conducted complaint investigation |
| Mayra Cota | Licensing Program Analyst | Conducted complaint investigation |
| Bobbie Rodriguez | Director of Memory Care | Met with investigators during visit |
| Wei Siew Ho | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Date: Aug 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not ensure a resident was adequately hydrated, which was received on 2024-09-16.
Complaint Details
The complaint alleged that a resident was hospitalized on 9/2 due to dehydration because staff did not provide water and ice during a heat wave and that the ice machine was locked after 5:00 p.m. The investigation found no evidence to substantiate this allegation.
Findings
The investigation found that the facility had multiple accessible water filtration systems and ice dispensers available 24/7, staff provided water and ice to residents during rounds and upon request, and residents confirmed access to water and ice. Record review did not corroborate the allegation of dehydration hospitalization. Therefore, the allegation was unsubstantiated.
Report Facts
Water filtration systems: 3
Staff interviews: 10
Resident interviews: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bobbie Rodriguez | Director of Memory Care Unit | Met with during the investigation and exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted the complaint investigation |
| Blanca Gonzalez | Licensing Program Analyst | Conducted subsequent visits during the investigation |
| Jeon | Licensing Program Analyst | Conducted initial 10-day visit |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Date: Aug 10, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-09-04 regarding medication management issues at Windsor Court Assisted Living Facility.
Complaint Details
The complaint alleged that the facility took resident's medication from the room without permission and did not order prescription refills on time. After interviews with staff (S1-S6), residents (R1-R10), and review of records including Physician Reports and Medication Administration Records, the allegations were found to be unsubstantiated.
Findings
The investigation found no evidence to substantiate the allegations that the facility took resident's medication without permission or failed to order prescription refills on time. Interviews with staff and residents, as well as record reviews, supported that medication was managed appropriately and administered on time.
Report Facts
Capacity: 130
Census: 130
Staff interviewed: 6
Residents interviewed: 10
Medication Administration Record review period: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bobbie Rodriguez | Director of Memory Care Unit | Met during investigation and involved in exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted investigation and signed report |
| Wei Siew Ho | Licensing Program Manager | Oversaw investigation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 1
Date: Jun 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-03-14 regarding staff neglect causing damage to a resident's motorized wheelchair and abandonment of a resident.
Complaint Details
The complaint investigation was conducted due to allegations of staff neglect involving damage to a resident's motorized wheelchair and abandonment. The wheelchair damage allegation was unsubstantiated, but the abandonment allegation was substantiated based on interviews and record review.
Findings
The allegation that staff broke a resident's motorized wheelchair was found to be unsubstantiated as the wheelchair battery had died and no staff were witnessed breaking residents' belongings. The allegation that a resident was abandoned due to staff neglect was substantiated; staff left the resident in a non-working wheelchair unable to call for assistance, posing a health and safety risk.
Deficiencies (1)
Residents must be free from punishment, humiliation, intimidation, abuse, or other punitive actions such as withholding residents’ money or interfering with daily living functions. The facility failed by leaving a resident in a non-working motorized wheelchair unable to call for assistance.
Report Facts
Capacity: 130
Census: 127
Deficiencies cited: 1
Plan of Correction Due Date: Jul 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Patrick McAdoo Morton | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 1
Date: Jun 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-03-12 regarding allegations that residents were not accorded dignity.
Complaint Details
The complaint was substantiated based on a preponderance of evidence. The allegation involved a staff member recording residents without consent. The staff member was terminated and corrective actions were taken including personal rights training for staff.
Findings
The investigation substantiated the allegation that a staff member (S1) recorded a video of two residents (R1 and R2) having intercourse without their permission or consent and shared it with staff. The staff member was terminated and other staff who saw the video and did not report it received final write-ups. Most interviewed staff denied knowledge of the video, and most residents stated staff had never recorded or taken pictures of them without permission.
Deficiencies (1)
R1 and R2 were video recorded by S1 having intercourse without their knowledge or consent, violating residents' personal rights and posing a health and safety risk.
Report Facts
Capacity: 130
Census: 127
Deficiency count: 1
Plan of Correction Due Date: Jul 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Tony Vasallo | Licensing Program Manager | Oversaw complaint investigation report |
| Patrick McAdoo Morton | Administrator | Facility administrator during investigation |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation visit |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Jun 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility did not report a resident missing and that a resident's needs were not being met.
Complaint Details
The complaint alleged that a resident was missing for two weeks and that the resident's needs were not being met, including being found shivering on a bed in a shared room instead of a private room. The investigation concluded these allegations were unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff, residents, and review of records indicated no resident was missing for two weeks and that residents' needs were being met. The allegations were therefore unsubstantiated.
Report Facts
Capacity: 130
Census: 127
Staff interviewed: 6
Residents interviewed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Aurelien Fruit | Administrator | Facility Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that the facility has vermin, specifically roaches in the food served to residents.
Complaint Details
The complaint alleged the presence of vermin, specifically roaches in residents' food. The allegation was unsubstantiated after investigation including facility tour, interviews, and pest control report review.
Findings
The investigation found no evidence of roaches or vermin during the facility tour and interviews with staff and residents. Pest control reports showed regular maintenance with no infestation reports in 2022. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 130
Census: 127
Complaint Control Number: 18-AS-20221227143725
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not providing proper accommodations to residents during a water main break in January 2023.
Complaint Details
The complaint alleged that during a water main break in January 2023, residents were not provided alternative accommodations, had not taken showers, were unable to flush toilets, and were not assisted with transporting water jugs. The investigation found no preponderance of evidence to substantiate these claims, resulting in an unsubstantiated finding.
Findings
The investigation included interviews with the administrator, staff, and residents. It was found that the facility provided bottled water and residents were able to shower and flush toilets, with no evidence supporting the allegation that residents were without water for days. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 130
Census: 127
Complaint Control Number: 18-AS-20230112103050
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Aurelien Fruit | Administrator | Met with during investigation and exit interview |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 130
Deficiencies: 2
Date: May 2, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not provide notice to residents of a rent increase.
Complaint Details
The complaint was substantiated based on record reviews and staff interviews. The facility did not provide adequate notice of rent increase to residents, charging them retroactively without clear communication of the new rates or effective dates.
Findings
The investigation substantiated the allegation that the facility failed to provide proper notice to residents regarding a rent increase. The facility charged residents retroactively without clearly outlining the new charges or effective date in the notice.
Deficiencies (2)
Failure to provide no less than 60 days' prior written notice to residents of rent increase as required by Health and Safety Code 1569.655(a).
Staff did not provide notice to residents of rent increase, posing a potential health and safety or personal rights risk to residents in care.
Report Facts
Capacity: 130
Census: 125
Resident files reviewed: 5
Billing history period: 4
Plan of Correction Due Date: May 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Seo Jeon | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rikesha Stamps | Licensing Program Manager | Oversaw the complaint investigation |
| Aurelien Fruit | Administrator | Facility administrator met during the investigation |
| Patrick McAdoo Morton | Administrator | Named as facility administrator in report header |
Inspection Report
Annual Inspection
Census: 126
Capacity: 130
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
Licensing Program Analyst Seo Jeon conducted an unannounced annual required visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and in compliance with infection control, physical plant, food service, care and supervision, and disaster preparedness requirements. No deficiencies were cited during the visit.
Report Facts
Staff members present: 30
Resident files reviewed: 10
Staff files reviewed: 5
Resident medications reviewed: 5
Fire extinguishers: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during the inspection |
| Seo Jeon | Licensing Program Analyst | Conducted the inspection visit |
| Rikesha Stamps | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 130
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not ensure the facility was free of pests.
Complaint Details
The complaint alleged that staff did not ensure the facility was free of pests. The allegation was found to be unsubstantiated based on records, observations, and interviews.
Findings
The investigation included a review of pest control service records, inspection of the facility kitchen, hallways, and residents' rooms, and interviews with residents and staff. No evidence of pests was found, and the allegation was determined to be unsubstantiated.
Report Facts
Resident interviews conducted: 10
Staff interviews conducted: 12
Pest control reports reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Seo Jeon | Licensing Program Analyst | Conducted the complaint investigation visit |
| Aurelien Fruit | Administrator | Facility administrator met during investigation |
| Rikesha Stamps | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-06-21 regarding staff not ensuring a resident's restroom was not leaking, free of mildew, and staff making inappropriate comments towards the resident.
Complaint Details
The complaint alleged that staff did not ensure the resident's restroom was not leaking, did not ensure the restroom was free of mildew, and that staff made inappropriate comments towards the resident. The investigation found the leak was repaired promptly, no mildew was observed, and inappropriate comments were alleged but not substantiated.
Findings
The investigation included observations, interviews, and record reviews. The leak in the resident's restroom was repaired within 48 hours, no mildew was observed during visits, and allegations of inappropriate comments were reported but unsubstantiated. The agency determined the allegations to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 130
Census: 127
Complaint received date: Jun 21, 2024
Leak repair timeframe: 6
Inspection start time: 900
Inspection end time: 1145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst and involved in investigation regarding allegations |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Anthony Brown | Maintenance Director | Provided information about the leak source and repair |
| Jazmond D Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 130
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not keep residents' rooms free from odor and that a resident's sink was in disrepair.
Complaint Details
The complaint was received on 2024-01-31 and alleged that staff did not keep residents' rooms free from odor and that a resident's sink was in disrepair. The allegations were found unsubstantiated due to insufficient evidence to prove the violations occurred.
Findings
The investigation found the allegations unsubstantiated after interviews, observations, and record reviews indicated that the mattress did not have a urine odor, the sink was in good repair and draining properly, and residents and staff reported no ongoing issues with odors or disrepair.
Report Facts
Capacity: 130
Census: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation |
| Samara Harris | Business and Development Director | Corroborated information regarding mattress condition |
| Anthony Brown | Maintenance Director | Provided information about sink repair status |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 130
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-02-07 regarding staffing, medication practices, staff responsiveness, and food service at Windsor Court Assisted Living Facility.
Complaint Details
The complaint investigation addressed four allegations: lack of staff to meet residents' needs, staff not responding to resident calls timely, staff medicating residents to keep them calm, and inadequate food service. All allegations were unsubstantiated after interviews with staff and residents, observations, and record reviews.
Findings
The investigation included interviews, observations, and record reviews. All allegations including lack of staff, delayed staff response, overmedication to keep residents calm, and inadequate food service were found to be unsubstantiated due to lack of corroborating evidence.
Report Facts
Capacity: 130
Census: 126
Staff interviewed: 3
Residents interviewed: 6
Food deliveries per week: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Carmina Meza | Director of Nurses | Met with Licensing Program Analyst during investigation and named in report |
| Patrick McAdoo Morton | Administrator | Facility administrator named in the report |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Aug 2, 2024
Visit Reason
The visit was an unannounced complaint investigation into an allegation that facility staff over-medicated a resident.
Complaint Details
The complaint alleged that facility staff over-medicated a resident and that the resident had medication not prescribed to them. The investigation included interviews, observations, and records review. The allegation was found unsubstantiated.
Findings
The investigation found no preponderance of evidence to prove the allegation of over-medication or administration of medication not prescribed to the resident; therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 130
Census: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Carmina Meza | Director of Nurses | Met with Licensing Program Analyst during investigation |
| Tricia Danielson | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Aug 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-06-03 regarding staff not ensuring residents' grooming needs are met and staff not responding to resident calls in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not ensuring residents' grooming needs and staff not responding timely to call buttons. Interviews with residents and staff, observations, and records review did not support the allegations.
Findings
The investigation found both allegations to be unsubstantiated based on observations, interviews with residents and staff, and records review. Residents were observed to be clean and well-groomed, and staff responded to call buttons in a timely manner according to interviews and observations.
Report Facts
Capacity: 130
Census: 127
Staff schedule: 3
Staff schedule: 1
Staff schedule: 2
Staff schedule: 1
Resident interviews: 5
Resident interviews: 6
Resident interviews: 5
Resident interviews: 6
Staff interviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Carmina Meza | Director of Nurses | Met with Licensing Program Analyst during investigation and named in findings |
| Tricia Danielson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Date: May 30, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not prevent residents from engaging in a physical altercation.
Complaint Details
The complaint alleged that staff did not prevent residents from engaging in a physical altercation. The investigation was unsubstantiated as there was no evidence that staff failed to prevent the incident.
Findings
The investigation found that a physical altercation occurred between two residents on May 17, 2024, resulting in injuries. Staff implemented increased monitoring and redirection plans after the incident. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 130
Census: 130
Date of physical altercation: May 17, 2024
Behavior monitoring period: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Aurelien Fruit | Administrator | Facility administrator involved in the investigation and exit interview |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: May 24, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that staff do not provide residents with a comfortable environment, the facility does not staff appropriately to meet residents' needs, and residents are not provided with activities.
Complaint Details
The complaint was received on 07/14/2021 alleging uncomfortable environment due to thermostat set to 90 degrees, insufficient staffing with only 1 caregiver for 97 residents, and lack of resident activities. The investigation found no evidence to support these allegations and deemed them unfounded.
Findings
Based on interviews, record reviews, and observations, the allegations were found to be unfounded. Residents have individual air-conditioning units, staffing levels were sufficient, and activities were planned and provided as scheduled.
Report Facts
Facility capacity: 130
Census: 129
Caregiver to resident ratio: 1
Residents per caregiver: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation visit |
| Carmina Meza | Licensed Vocational Nurse (LVN) | Met with during investigation and received report copy |
| Patrick McAdoo Morton | Administrator | Named as facility administrator in complaint |
| Jazmond D Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: Apr 29, 2024
Visit Reason
The visit was conducted as an unannounced complaint investigation following a complaint received on 2021-06-21 alleging that staff spoke inappropriately to a resident in care.
Complaint Details
The complaint alleged that staff spoke inappropriately to a resident. The investigation included interviews, record reviews, and observations. The allegation was found unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff spoke inappropriately to a resident. The two staff members referenced were no longer employed, and the resident did not recall the incident clearly. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 130
Census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation |
| Aurelien Fruit | Administrator | Met with the Licensing Program Analyst during the investigation |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: Mar 22, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2021-06-21 regarding failure to provide an Admissions Agreement, improper medication administration, and overcharging in retaliation.
Complaint Details
The complaint alleged that a resident was not provided with an Admissions Agreement, staff were not administering medications according to physician orders, and the facility was overcharging the resident in retaliation. The investigation found these allegations to be unsubstantiated and unfounded.
Findings
The investigation found no evidence to support the allegations. The resident had signed the Admissions Agreement, medications were administered according to physician orders, and there was no overcharging as insurance and hospice covered services. The allegations were deemed unfounded.
Report Facts
Capacity: 130
Census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Brittany Holm | Administrator | Facility administrator met during investigation |
| Aurelien Fruit | Administrator | Facility representative met during investigation and received report |
Inspection Report
Annual Inspection
Census: 129
Capacity: 130
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with state regulations.
Findings
The facility was found to be clean, well-maintained, and in compliance with all applicable regulations. No deficiencies were observed during the inspection.
Report Facts
Staff present: 29
Client records reviewed: 5
Employee records reviewed: 5
Food supply duration: 1
Food supply duration: 2
Water temperature: 106
Fire extinguishers: 24
Gated pools: 1
Gates bordering memory care: 2
Emergency supplies observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aurelien Fruit | Administrator | Conducted and completed the facility tour; certificate expiration date is 08/01/2024 |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the annual inspection |
| Jazmond D Harris | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that residents engaged in a physical altercation resulting in injuries.
Complaint Details
The complaint alleged that due to staff’s neglect and lack of supervision, residents got into a physical altercation resulting in severe injuries. The investigation included review of facility, hospital, and law enforcement records, and interviews with staff and residents. It was found that Resident 1 entered Resident 2's room erroneously, leading to a physical altercation. Staff responded immediately to separate the residents. The allegation was unsubstantiated due to insufficient evidence of neglect or lack of supervision.
Findings
The investigation found that a physical altercation occurred between two residents resulting in injuries, but there was insufficient evidence to prove neglect or lack of supervision by facility staff. The allegation was determined to be unsubstantiated and no citations were issued.
Report Facts
Capacity: 130
Census: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rikesha Stamps | Licensing Program Manager | Named in report as Licensing Program Manager |
| Patrick McAdoo Morton | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 1
Date: Jan 10, 2024
Visit Reason
The visit was conducted as part of a complaint investigation related to allegations that tuberculosis (TB) tests were not being regularly asked and checked by the facility.
Complaint Details
Complaint Control number: 18-AS-20231026092156. The complaint alleged that TB tests were not being regularly asked and checked by the facility. The investigation substantiated that one staff member lacked a TB test result on file.
Findings
The Licensing Program Analyst reviewed staff files and found that one staff member did not have a TB test result on file. Four out of five randomly checked staff had TB test results documented. A technical violation was issued for failure to have TB test results on file as required by Title 22, Division 6 Health and Safety Code 1796.45 (a). There were no health and safety concerns at this time.
Deficiencies (1)
Staff member S1 did not have a TB test result on file with the facility.
Report Facts
Staff TB test results reviewed: 5
Staff with TB test results on file: 4
Facility census: 127
Facility capacity: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation and issued the technical violation |
| Aurelien Fruit | Administrator | Facility administrator who received the technical violation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Jan 10, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff did not administer a resident's medication in a timely manner.
Complaint Details
The complaint alleged that staff did not administer medication for Resident 1 in a timely manner. The investigation included observation, interviews, and record review, which showed the medication was given as prescribed. The complaint was found to be unfounded.
Findings
The investigation found that the medication was administered to the resident twice according to doctor's orders, and the allegation was determined to be unfounded.
Report Facts
Capacity: 130
Census: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: Nov 7, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that the facility did not follow eviction procedures, including failure to provide a 30-day eviction notice, improper service of the resident, and lack of resources for alternative housing.
Complaint Details
The complaint alleged that the facility did not follow eviction procedures, including not following the 30-day eviction notice, improper service to the resident, and failure to provide resources for alternative housing. The complaint was investigated and found to be unfounded.
Findings
Based on observations, interviews, and record review, the complaint was found to be unfounded. The resident was properly served with the 30-day eviction notice, and the facility provided resources to help find alternate housing. The complaint was dismissed.
Report Facts
Outstanding balance fees: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Patrick McAdoo Morton | Administrator | Facility Administrator named in the report |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Census: 129
Capacity: 130
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The visit was an unannounced case management visit focused on the health, safety, and welfare of residents, triggered by a serious incident report regarding a resident who left the facility and was absent without leave for approximately 2 hours.
Findings
The Licensing Program Analyst toured the facility and found all utilities operating properly, sufficient food supply, and no immediate concerns for residents. No deficiencies or civil penalties were cited based on the visit.
Report Facts
Resident AWOL duration (hours): 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during the case management visit and participated in the exit interview. |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Jazmond D Harris | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-09-15 alleging that staff did not provide a comfortable environment for a resident and did not safeguard a resident's personal property.
Complaint Details
The complaint alleged that staff did not provide a comfortable environment for Resident #1, including incidents with roommates involving verbal abuse and unauthorized use of property. Another allegation was that staff did not safeguard Resident #1's personal property. The investigation found the first allegation unfounded and the second unsubstantiated.
Findings
The investigation included observations, interviews, and record reviews. The allegation that staff did not provide a comfortable environment for the resident was found to be unfounded. The allegation that staff did not safeguard the resident's personal property was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 130
Census: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-09-07 regarding staff not emptying resident trash bins timely, improper cleaning of restrooms, unclean patio furniture, and debris on the dining room floor.
Complaint Details
The complaint was investigated and deemed unfounded, meaning the allegations were false, could not have happened, or lacked reasonable basis.
Findings
Based on observations, interviews, and record reviews, the allegations were found to be unfounded. The facility was observed to be clean, with proper cleaning protocols and schedules in place, and residents denied any issues with trash emptying or cleanliness.
Report Facts
Capacity: 130
Census: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on report |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation and received report |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Date: Oct 16, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not following a resident's care plan and mismanaged resident's medication.
Complaint Details
The complaint alleged that staff were not following the resident's care plan and mismanaged medication. The investigation concluded the allegations were unsubstantiated.
Findings
The investigation found that the facility did not receive proper medication orders for Resident #1 and followed procedures by not distributing medication without orders. Medication was properly destroyed and logged. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 130
Census: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation |
| Patrick McAdoo Morton | Administrator | Named as facility administrator |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: Oct 4, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2023-08-07 regarding inadequate supervision resulting in resident falls and injuries, failure to seek medical attention, neglect in resident hygiene and bedding care, failure to dispose of resident trash, and refusal to assist residents.
Complaint Details
The complaint investigation was unsubstantiated based on observations, interviews, and record reviews. Allegations included inadequate supervision leading to resident falls and injuries, failure to seek medical attention, neglect in resident hygiene and bedding, failure to dispose of trash, and refusal to assist residents. Residents and staff interviews indicated residents could request and receive assistance in a reasonable time, and the facility met regulatory requirements.
Findings
The investigation included observations, interviews with staff and residents, and record reviews. The evidence did not support the allegations, and the complaints were determined to be unsubstantiated at this time.
Report Facts
Facility capacity: 130
Resident census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Aurelien Fruit | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: Oct 4, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations received on 2023-08-15 regarding staff not preventing resident-to-resident aggression, mishandling medical needs, and failure to repair facility elevators.
Complaint Details
The complaint included allegations that staff did not prevent a resident from kicking another resident, did not prevent inappropriate sexual interactions between residents, mishandled a resident's medical needs, and failed to repair the facility's elevators. After investigation, all allegations were found unsubstantiated or unfounded.
Findings
The investigation found no substantiated evidence supporting the allegations. Medication administration was properly documented, residents reported their needs were met, and elevators were observed to be in working condition. The facility took measures to address roommate conflicts. All allegations were determined to be unsubstantiated or unfounded.
Report Facts
Facility capacity: 130
Census: 129
Number of elevators: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: May 22, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-05-18 regarding allegations that facility staff did not safeguard a resident's belongings.
Complaint Details
The complaint alleged that facility staff did not safeguard resident's belongings, specifically dentures of Resident #1. The investigation found that Resident #1 was admitted with dentures, but they were missing after a hospital visit. Staff reported the dentures were sent with the resident and would not have been left in the dining room. The facility's theft and loss policy states they are not responsible for lost or stolen items. The allegation was unsubstantiated.
Findings
The investigation included observation, interviews, and record review. The allegation that facility staff did not safeguard resident's belongings was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 130
Census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
| Aurelien Fruit | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 1
Date: May 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that a resident hit another resident in care and that the facility was not providing a safe environment for residents.
Complaint Details
The complaint investigation was initiated due to an allegation that Resident #2 hit Resident #1 three times in the forehead with a closed fist on or around May 9, 2023. Resident #1 was visibly fearful of Resident #2 and requested their door be locked. Staff interviews indicated Resident #2 wanders frequently and enters other residents' rooms. The allegation of resident hitting was substantiated, while the allegation that the facility was not providing a safe environment was unsubstantiated.
Findings
The allegation that a resident hit another resident was substantiated based on interviews, observations, and record review, with no visible injuries noted. The allegation that the facility was not providing a safe environment was unsubstantiated as staff were responsive and safety measures were in place.
Deficiencies (1)
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. The licensee did not ensure R1 was afforded dignity when hit by R2 while in care, posing a potential health, safety, and personal rights risk.
Report Facts
Capacity: 130
Census: 129
Staff on shift: 4
Deficiency due date: May 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joel Esquivel | Licensing Program Manager | Oversaw the complaint investigation |
| Aurelien Fruit | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 1
Date: May 16, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that the licensee allowed staff without criminal record clearance to work in the facility and that staff failed to administer a resident's medication as prescribed.
Complaint Details
The complaint was substantiated for the allegation of staff without criminal record clearance working at the facility. The medication administration allegation was found to be unfounded due to lack of physician's order.
Findings
The allegation that staff without criminal record clearance were allowed to work was substantiated, with one staff member not properly associated with the facility. The allegation that staff failed to administer medication as prescribed was unfounded due to lack of physician's order supporting the medication administration directive from the resident's Power of Attorney.
Deficiencies (1)
Licensee did not ensure that staff member Maria A. was associated to the facility prior to beginning employment, violating criminal record clearance requirements.
Report Facts
Staff working: 27
Facility capacity: 130
Resident census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Licensing Program Manager | Oversaw the complaint investigation |
| Aurelien Fruit | Administrator | Facility administrator met during investigation and exit interview |
| Maria A. | Staff member not associated with the facility prior to employment |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: May 16, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were mismanaging residents' medication and not treating residents with dignity or respect.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.
Findings
The investigation found both allegations to be unfounded based on observations, interviews with residents, and record reviews. Residents reported being treated with dignity and respect, and medication was administered as prescribed.
Report Facts
Facility capacity: 130
Census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: May 16, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that the facility held a resident against their will, staff did not ensure proper sanitation, and staff switched resident rooms without consent.
Complaint Details
The complaint investigation was triggered by allegations including holding a resident against their will, improper sanitation, and switching resident rooms without consent. All allegations were investigated through observation, interviews, and record review and were found to be unfounded.
Findings
The investigation found all allegations to be unfounded. The resident was not held against their will, the facility was observed to be clean and properly sanitized, and the resident room switch was mutually agreed upon with consent.
Report Facts
Capacity: 130
Census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
| Patrick Mcadoo Morton | Administrator | Previous Administrator involved in investigation findings |
| Aurelien Fruit | Administrator | Met with Licensing Program Analyst during investigation |
| Carminia Meza | Director of Nursing | Provided information regarding resident room switch |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 130
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that the facility is unsanitary.
Complaint Details
The complaint alleged that the facility was unsanitary. The investigation found the allegation to be unfounded, meaning it was false or without reasonable basis.
Findings
The facility was observed to be clean and clutter free, with clean resident rooms and bathrooms. Interviews and observations found no evidence supporting the allegation. The complaint was determined to be unfounded.
Report Facts
Capacity: 130
Census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McAdoo Morton | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Javina George | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 130
Deficiencies: 0
Date: Mar 20, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation of illegal eviction at Windsor Court Assisted Living Facility.
Complaint Details
The complaint alleged illegal eviction. The investigation included observation, interviews, and record review. The allegation was found to be unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the allegation of illegal eviction was unfounded. Although Resident #1 intended to sell Resident #2's ring without their knowledge, there was no evidence of illegal eviction, and the complaint was dismissed.
Report Facts
Capacity: 130
Census: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McAdoo Morton | Administrator | Named in relation to the investigation and findings |
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Carminia Meza | Director of Nursing | Present during the investigation |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 130
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
The visit was conducted to investigate a complaint alleging that facility staff were not providing adequate food service to a resident.
Complaint Details
The complaint alleged that facility staff were not providing adequate food service to a resident (R1). The allegation was unsubstantiated after interviews, observations, and document reviews, including incident reports and doctor's notes.
Findings
The investigation found no evidence to support the allegation that the resident was without food for two weeks. The resident had refused dinner for three days but ate other meals, and the allegation was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 18-AS-20221227143725
Complaint received date: Dec 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janira Arreola | Licensing Program Analyst | Conducted the complaint investigation visit and interviews. |
| Carminia Meza | Director of Nursing | Interviewed during the investigation and provided information regarding the allegation. |
| Joel Esquivel | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 130
Deficiencies: 1
Date: Aug 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 08/18/2022 regarding resident care and facility practices at Windsor Court Assisted Living Facility.
Complaint Details
The complaint was substantiated regarding staff failing to prevent a resident (R1) from eloping on 4/4/22 by unfastening a window screw and scaling a wall. Staff did not check on the resident for over two hours. Other allegations were unsubstantiated or unfounded after interviews and record reviews.
Findings
The investigation substantiated the allegation that staff did not prevent a resident from wandering away from the facility, resulting in a cited deficiency. Other allegations including refusal to provide medical records, not following physician orders, failure to notify authorized representatives of incidents, taking resident's phone away, denying visitors, and restricting participation in activities were found to be unsubstantiated or unfounded.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual needs, evidenced by a resident eloping from the facility without staff knowledge.
Report Facts
Capacity: 130
Census: 128
Deficiencies cited: 1
Plan of Correction due date: Aug 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joel Esquivel | Licensing Program Manager | Oversaw the complaint investigation |
| Bobbie Rodriguez | Memory Care Director | Facility staff member interviewed during investigation and recipient of report |
| Patrick McAdoo Morton | Administrator | Facility administrator interviewed regarding medical records and other allegations |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 4
Date: Jul 14, 2022
Visit Reason
The inspection was conducted as a case management investigation triggered by a complaint (#18-AS-20220706102318) regarding resident safety and care issues.
Complaint Details
Investigation was based on complaint #18-AS-20220706102318. The complaint was substantiated with multiple deficiencies cited related to resident safety, reporting, documentation, and medication administration.
Findings
The facility was found deficient for failing to report incidents of physical violence by one resident (R1) against others, failing to document abuse in victim files, not conducting a re-assessment of R1 after behavioral changes, and camouflaging medication without the resident's knowledge, all of which posed safety and personal rights violations.
Deficiencies (4)
Failure to report incidents of physical violence by resident R1 to Licensing.
Failure to document abuse/violence incidents in the victim residents' files.
Failure to conduct a re-assessment of resident R1 after marked behavioral changes.
Camouflaging medication in resident R1's juice without their knowledge to administer medication.
Report Facts
Census: 130
Total Capacity: 130
Plan of Correction Due Date: Jul 15, 2022
Plan of Correction Due Date: Jul 29, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Mcadoo Morton | Administrator | Facility administrator involved in exit interview and findings discussion |
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joel Esquivel | Licensing Program Manager | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 1
Date: Jul 14, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not provide a safe environment for residents in care.
Complaint Details
The complaint was substantiated based on record review and interviews showing that resident R1 exhibited increased aggressive behavior starting 6/8/22, including hitting, kicking, and spitting. The facility failed to act to protect other residents until R1 was placed on psychiatric hold on 7/1/22 and subsequently issued an eviction notice.
Findings
The investigation substantiated the allegation that the facility failed to provide a safe environment, as resident R1 exhibited aggressive behavior towards staff and other residents for nearly two months before being placed on psychiatric hold and issued an eviction notice. The facility was cited for deficiencies related to personal rights and safety.
Deficiencies (1)
Personal Rights of Residents in All Facilities: Residents shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by R1's physical and verbal aggression towards multiple residents for nearly 2 months prior to removal, posing an immediate safety risk.
Report Facts
Census: 130
Total Capacity: 130
Staff notes: 10
Plan of Correction Due Date: Jul 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Mcadoo Morton | Administrator | Met during investigation and named in findings |
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation |
| Bobbie Rodgriguez | Memory Care Director | Met during investigation and named in findings |
| Joel Esquivel | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 117
Capacity: 130
Deficiencies: 0
Date: Mar 1, 2022
Visit Reason
The inspection was an unannounced annual inspection limited to infection control to evaluate the facility's compliance with COVID-19 best practices and mitigation measures.
Findings
The facility was found to have sufficient PPE supplies for a 30-day period, proper infection control training for staff, ongoing COVID-19 testing twice a week, and symptom monitoring for residents, staff, and visitors. Hand sanitizer and soap supplies were adequate, and visitor screening logs were maintained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McAdoo Morton | Administrator | Met with Licensing Program Analyst during inspection and confirmed infection control practices. |
| Crystal Colvin | Licensing Program Analyst | Conducted the annual infection control inspection. |
| Joel Esquivel | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 130
Deficiencies: 0
Date: Jan 24, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 09/17/2020 regarding staff neglect leading to resident pressure injuries, residents being left in soiled diapers for extended periods, and failure to meet residents' needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff neglect causing pressure injuries, residents left in soiled diapers, and failure to meet resident needs. Interviews with staff and residents and documentation review did not support the allegations.
Findings
The investigation included interviews and record reviews and found that pressure injuries were being cared for by a home health agency, residents were not left in soiled diapers for extended periods, and resident care needs were being met appropriately. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 130
Census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Patrick McAdoo-Morton | Administrator | Facility administrator present during investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 130
Deficiencies: 0
Date: Dec 20, 2021
Visit Reason
The visit was an unannounced case management visit triggered by a Special Incident Report received on December 17, 2021, concerning inappropriate behavior between two residents.
Complaint Details
The complaint involved Resident One engaging in inappropriate behavior with Resident Two. The complaint was investigated and found to be unsubstantiated with no violations.
Findings
The investigation found no violations of Title 22 and no citations were issued. The facility followed protocol and the investigation was completed with no deficiencies observed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McAdoo Morton | Administrator | Met with Licensing Program Analyst during the visit and involved in the exit interview. |
| Jesse Gardner | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Reyna Lacey | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 130
Deficiencies: 2
Date: Jun 28, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 05/27/2020 regarding facility staff's adherence to admission agreements and notification of fee increases.
Complaint Details
The complaint investigation was substantiated for allegations that facility staff did not adhere to admission agreement terms and failed to timely inform resident's responsible party of fee increase. Allegations that facility staff did not ensure resident's room was cleaned and did not provide adequate food service were unsubstantiated.
Findings
Two allegations were substantiated: the facility failed to comply with the terms of the admission agreement, including lack of a signed agreement for a temporary monthly rate, and failed to provide a 60-day prior written notice to residents' responsible parties regarding fee increases. Two other allegations regarding room cleanliness and adequacy of food service were found unsubstantiated.
Deficiencies (2)
Facility failed to comply with admissions agreements and could not provide proof of signed agreement for temporary rate.
Facility failed to provide a 60-day prior written notice to residents before fee increase.
Report Facts
Capacity: 130
Census: 111
Deficiencies cited: 2
POC Due Date: Jul 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Gayoso | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Karen Clemons | Licensing Program Manager | Oversaw complaint investigation |
| Patrick McAdoo-Morton | Facility representative interviewed during investigation | |
| Brittany Holm | Administrator | Facility administrator during investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 130
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2019-12-12 regarding allegations against Windsor Court Assisted Living Facility.
Complaint Details
The complaint involved allegations that the facility was not adhering to the Admission Agreement and charged a resident for services not provided. The investigation was unsubstantiated due to lack of evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations that the facility did not adhere to the admission agreement or charged a resident for services not provided. The allegations were determined to be unsubstantiated.
Report Facts
Complaint received date: Dec 12, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaunte Henry | Licensing Program Analyst | Conducted the complaint investigation and tele-visit |
| Patrick McAdoo-Morton | Administrator | Met with Licensing Program Analyst during investigation |
| Edna Musoke | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Capacity: 130
Deficiencies: 0
Date: Jan 26, 2021
Visit Reason
The visit was a Case Management follow-up conducted via FaceTime due to COVID-19 to verify the removal of two individuals (Person #1 and Person #2) from the facility's workforce.
Findings
The verification confirmed that Person #1 and Person #2 never started working at the facility and have never been employed there. The removal verification was completed with no deficiencies noted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Bernal | Business Office Manager | Met with Licensing Program Analyst and provided information regarding employment status of Person #1 and Person #2. |
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