Windsor Court Assisted Living

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Director of Nurses Carmina Meza and explained the purpose of the visit. LPA’s complaint investigation consisted of a tour of the interior/exterior areas of the facility, observations, interviews with staff and residents, and records review of requested pertinent documents. Regarding the allegation “Facility staff over-medicated resident”, it was reported Resident One (R1) was overmedicated and had in their possession half a tablet of medication that did not belong to R1. Records review of facility progress report dated 05/30/2021 shows R1 was having a behavior in the AM and refused to take their AM medication. R1’S Power of Attorney (POA) was called and POA stated they would arrive to the facility at 1:00pm. Staff contacted 911 services at 10:50am to seek additional assistance due to safety concerns for staff and other residentsRead the full finding— CDSS inspection report, August 2, 2024 · control 18-AS-20210602143558

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Director of Nurses Carmina Meza and explained the purpose of the visit. LPA’s complaint investigation consisted of a tour of the interior/exterior areas of the facility, observations, interviews with staff and residents, and records review of requested pertinent documents. Regarding the allegation “Staff do not ensure that resident's grooming needs are met” it was reported staff are not assisting residents with their grooming needs. Interview with five (5) out of six (6) residents reported staff are assisting residents with their grooming needs. Interview with Resident One (R1) reported they receive showers from caregivers twice a week has not experienced issues with caregivers assisting R1 with their activities of daily living (ADL). Interviews with four (4) staff revealed staff are assisting residents with their grooming and hyRead the full finding— CDSS inspection report, August 2, 2024 · control 18-AS-20240603143759

Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA was granted entry and met with Administrator Aurelien Fruit who was informed of the purpose of the visit and the elements of the allegation. During today's visit, LPA toured the facility, conducted staff and resident interviews, and reviewed documentation pertinent to Resident One (R1) and Resident Two (R2). Regarding the allegation “Staff did not prevent the residents from engaging in a physical altercation” it was reported a physical altercation occurred between R1 and R2 on May 17, 2024. R2 was sent to urgent care due to injuries sustained to the back of the head and R1 had a bruise on their left eye but refused medical treatment. Based on interviews conducted, R2 walked into R1’s room and initiated the physical altercation due to a closet door being left open. R2 reported R1 had used their cane to hit R2 on the backRead the full finding— CDSS inspection report, May 30, 2024 · control 18-AS-20240521122020

On May 24, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted a visit to the facility and met with Carminia Meza, (LVN). The visit was conducted to provide the findings for the investigation pertaining to the listed allegations. During the investigation the LPA conducted staff and resident interviews, record reviews, and made observations pertaining to the listed allegations. On July 14, 2021, Community Care Licensing (CCL) received a complaint alleging staff does not provide residents with a comfortable environment, the facility does not staff appropriately to meet the residents' needs, and the residents are not provided with activities. It was reported that the administrator turned down the AC thermostat to 90 degrees. And that the facility was very hot. Regarding the allegation staff does not provide residents with a comfortable environment, it was reported that the air-conditioning thermostat was turned down to 90 degrees. The information obtained from staff and residentRead the full finding— CDSS inspection report, May 24, 2024 · control 18-AS-20210714121632

On April 29, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to the facility to conducted additional interviews and conclude the investigation. LPA Mixson met with the Administrator, Aurelien Fruit, and stated the purpose of the visit. During the investigation, LPAs conducted staff and resident interviews, record reviews, and made observations pertaining to the listed allegation. On June 21, 2021, Community Care Licensing received a complaint alleging that staff speak inappropriately to a resident in care. It was reported that Resident Number 1 (R1), got angry and argued with the previous Administrator over various issues (R1) was having. It was also reported that the previous Administrator told (R1) "You can either go to jail, go to you room, or take the meds you've been given." Regarding the allegation Staff speak inappropriately to resident in care, it was advised that the two staff referenced in the allegation, ("Patrick" and "Jennifer") are no longer workinRead the full finding— CDSS inspection report, April 29, 2024 · control 18-AS-20210621122750

On March 22, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to deliver the findings and met with the Administrator. The visit was made to provide the findings for the investigation pertaining to the listed allegation. During the investigation, the LPA conducted staff and resident interviews, record reviews, and made observations pertaining to the listed allegation. On June 21, 2021, Community Care Licensing received a complaint alleging a Resident (R1), was not provided with an Admissions Agreement. It was reported that R1 was not provided a copy of their Admissions Agreement upon the transfer from the California Nursing and Rehabilitation Center to the listed facility. Regarding the allegation resident was not provided an admission agreement, it was advised that it is the policy and procedure to have each resident read, sign, and date their Admissions Agreement. Additionally, it was advised, if a resident is not able to sign and date the admissRead the full finding— CDSS inspection report, March 22, 2024 · control 18-AS-20210621122750

Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced to deliver findings for the complaint investigation related to the above listed allegation. LPA met with Business Office Manager Mariahoney Malasig and explained the purpose of today’s visit. LPA then toured the facility. Administrator Aurelien Fruit arrived while in the facility. During the investigation, the Department reviewed facility records, hospital records and law enforcement records. The Department also conducted interviews with the facility staff and residents. *Continued on LIC9099C Unsubstantiated— CDSS inspection report, January 11, 2024 · control 18-AS-20220126125405

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to deliver findings for a complaint investigation regarding the allegations listed above. LPA met with Administrator, Aurelien Fruit and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 10/26/2023, Community Care Licensing received a complaint stating that the staff did not administer resident’s medication in a timely manner. In regards to the allegation that the staff did not administer medication for Resident 1 (R1), it was reported that the facility did not apply and give R1 their prescribed treatment. LPA Banrasavong spoke to R1 who confirmed that they were provided their treatment twice. UnfoundedRead the full finding— CDSS inspection report, January 10, 2024 · control 18-AS-20231026092156

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegations listed above. LPA met with Administrator, Aurelien Fruit and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 10/25/2023, Community Care Licensing received a complaint stating that the facility did not follow eviction procedures. The allegation stated that the facility did not follow the 30-day eviction notice, did not properly serve the resident, and did not give the resident proper resources to find alternative housing. During the LPA’s initial visit, LPA was able to speak to Resident 1 (R1) and confirmed that he was properly served with the 30-day notice on the date that the facility submitted the notice to Community Care Licensing’s Regional Office. Continued onRead the full finding— CDSS inspection report, November 7, 2023 · control 18-AS-20231025153653

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA met with Administrator, Aurelien Fruit and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 09/15/2023, Community Care Licensing received a complaint stating that facility staff did not provide a comfortable environment for resident. In regards to the allegation that the staff did not provide a comfortable environment for resident, it was reported that Resident #1 (R1) had several incidents with R1’s roommate (R2). It was alleged that R2 was verbally abusive towards R1 and R2 used R1’s property without permission. (Continued on LIC9099C) UnfoundedRead the full finding— CDSS inspection report, October 20, 2023 · control 18-AS-20230915083849

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegations listed above. LPA met with Administrator, Aurelien Fruit, and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 09/07/2023, Community Care Licensing received a complaint stating that staff are not emptying resident trash bins in a timely manner, staff are not properly cleaning facility restrooms, staff do not ensure facility patio furniture are cleaned, and staff do not keep dining room floor free from debris. (Continued on 9099-C) UnfoundedRead the full finding— CDSS inspection report, October 20, 2023 · control 18-AS-20230907152452

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegations listed above. LPA met with Administrator, Aurelien Fruit, and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. On 08/18/2023, Community Care Licensing received a complaint stating that facility staff are not following resident's care plan and staff mismanaged resident's medication. In regards to the allegation that staff did not follow the residents care plan, it was reported that the facility did not follow orders from Above and Beyond Hospice for Resident #1. The order was for medication queued date of 08/10/2023. Medication was never given or distributed due to the facility not receiving order and directions to distribute the medication. Information obtained from inRead the full finding— CDSS inspection report, October 16, 2023 · control 18-AS-20230818125146

Licensing Program Analyst (LPA) Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegation(s) listed above. LPA met with Administrator, Aurelien Fruit, where LPA explained the purpose of the visit and the elements of the allegation(s). The allegation(s) were investigated, the investigation consisted of observation, interviews with five (5) staff members and five (5) residents, and record review. On 08/07/2023, Community Care Licensing received a complaint stating that the following allegations: Staff did not provide adequate supervision resulting in resident suffering a fall and sustaining injuries, Facility did not seek medical attention for a resident in care, Staff left resident soiled for a long period of time, Staff did not replace resident's bedding, Staff did not dispose of resident's trash, Staff refused to assist a resident in care. (Continued on 9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, October 4, 2023 · control 18-AS-20230807114540

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to commence a complaint with the above allegations. LPA met with Administrator, Aurelien Fruit, where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and record review. On 08/15/2023, Community Care Licensing received a complaint alleging that staff did not prevent a resident from kicking another resident while in care, staff did not prevent a resident from engaging in inappropriate sexual interactions with another resident while in care, staff do not repair the facility's elevators, and staff are mishandling a resident's medical needs while in care. In regards to the allegation that staff mishandling the resident’s medical needs while in care. It was reported that staff missed medication distribution for Resident #1. Residents indicated that they have their medical needs met and if medicRead the full finding— CDSS inspection report, October 4, 2023 · control 18-AS-20230815144142

Licesning Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation. LPA met with Aurelien Fruit, Administrator where LPA informed the purpose of LPA's visit and explained the elements of the allegation. The allegation was investigated, the investigation consisted of observation, interviews and record review. Regarding the allegation of facility staff did not safeguard resident's belongings. Resident #1 (R1) was admitted to the facility on April 24, 2021. Per R1's personal property inventory form R1 was admitted with 1 pair of dentures. On May 6, 2023 while R1 was eating in th dining room, they were observed to appear to have been sleeping, and clammy. As a result R1 was sent out for medical observation. Upon R1's return to the facility on May 8, 2023, they were observed to have been without their dentures when eating breakfast. Interviews conducted with Staff #1 (S1) and staff #2 (S2) revealed that R1 stated that they had leftRead the full finding— CDSS inspection report, May 22, 2023 · control 18-AS-20230518105420

Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence a complaint investigation regarding the allegation(s) listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit and the elements of the allegations. The allegation was investigated, the investigation consisted of observation, interviews and record review. Regarding the allegation of Licensee allowed staff without criminal record clearance to work in the facility. LPA requested a copy of the staff schedule and was provided a list of staff that were working at the facility. Per the list there were 27 staff working, of the 27 staff, LPA observed for Staff #1 (S1) that has obtained fingerprint clearance but was not associated to the facility. Based on observation and record review the allegation of licensee allowed staff without criminal record clearance to work in facility is SUBSTANTIATED. An exit interview was conducted and a copy of this report, appeal rights, LIC621Read the full finding— CDSS inspection report, May 16, 2023 · control 18-AS-20230512141034

Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence a complaint investigation regarding the allegation listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observation, interviews and record review. Regarding the allegation of resident hit another resident in care. It was reported that on or around May 9, 2023 Resident #1 (R1) was hit in the middle of their forehead three times with a closed fist by Resident #2 (R2). LPA interviewed R1 who was observed to be visibly fearful of R2 as evidenced by the request to have their door locked, and stating that they did not want to speak or be around R2. During the interview with R1, R1 stated that about a week ago, R2 was found inside of their closet, looking through their clothes, when R1 asked for R2 to get out, R2 then proceeded to hit R1 three times with a closed fist inRead the full finding— CDSS inspection report, May 16, 2023 · control 18-AS-20230510154004

Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence a complaint investigation regarding the allegation listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observation, interviews and record review. Reagrding the allegation of facility held resident against their will. Resident #1 (R1) had been residing for the facility for one week. It was reported that on March 27, 2023 R1 was trying to leave the facility, and that all facility staff were blockng the doors and laughing them.Per previous Administrator Patrick Mcadoo Morton R1 was sent out for a medical evaluation, and that no one prevented them from leaving, as the doors are unlocked and it is not a secured perimeter. Patrick does not have any knoweledge of anyone refusing to let R1 leave. In addition to R1 being sent out, R1 had thrown themself on the ground, andRead the full finding— CDSS inspection report, May 16, 2023 · control 18-AS-20230328114539

Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence a complaint investigation regarding the allegation listed above. LPA met with Administrator Aurelien Fruit and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observation, interviews and record review. Regarding the allegation of staff are mismanaging resident's medication. LPA reviewed Resident #1 (R1). LPA observed for R1's medication to be accounted for and to have been given as prescribed. There was a prescription for a narcotic that was to be given every five hours from the time that the dosage was given, however R1 believed that the medication was supposed to be given every five hours on the dot. In addition during interviews conducted R1 stated that they believed that they were given their medication prescribed as that was not an issue. Based on observation, interviews and record review the allegation of staffRead the full finding— CDSS inspection report, May 16, 2023 · control 18-AS-20230330182415

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct and investigation regarding the allegation listed above. LPA met with Adminitrator Patrick McAdoo Morton and explained the purpose of the visit and the elements of the allegation. The investigation consisted of observation, interview, record review. Regarding the allegation of facility is unsanitary. LPA conducted a tour of the interior and the exterior of the facility. The facility was observed to be clean and clutter free, with the aroma of cookies being baked in the lobby. A walk thru of resident bedrooms was conducted and revealed for the rooms and bathrooms to be clean. Per Administrator Patrick the facility has an outsourced cleaning company that comes and completes housekeeping related tasks. Housekeeping occurs seven days a week. The facility does have a pool that is cleaned once a week. Additionally feedback provided during interviews revealed that there is not any concerns thatRead the full finding— CDSS inspection report, March 28, 2023 · control 18-AS-20230324143945

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct and investigation regarding the allegation listed above. The investigation consisted of observation, interview, record review. Regarding the allegation illegal eviction. On March 14, 2023 the regional office received a copy of an eviction notice that was issued on March 13, 2023 to Resident #1 (R1). Interviews conducted and documentation reviewed revealed that R1 had asked for assistance from Staff #1 (S1), with uploading photos of a ring to their Ebay account. It was discovered that the ring was a Law school class ring that was engraved with Resident #2 (R2)'s name. R2 was not aware that the ring was "missing". (S1) handed R2 their ring which they thought was in their room in a box. R1 informed Administrator that R2 had brought a bunch of jewlery to their room for them to look the items up on ebay, early on March 13, 2023. The items were placed on R1's bed and a ring may have fallen offRead the full finding— CDSS inspection report, March 20, 2023 · control 18-AS-20230314153510

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the fscility on 01/06/2023 at 2:30 p. m. in order to conduct an investigation into the above allegation. LPA met with Director of Nursing, Carminia Meza, who was informed of the purpose of the visit. During the visit, LPA conducted interviews, conducted observations, and collected documentation as it pertained to the allegation. It was alleged that R1 has not been provided food in at least (2) weeks. LPA conducted interview with nursing director who denied the allegation, and stated that the resident had refused to eat dinner for (3) days from the period of 12/26/2022 to 12/28/2022, but had eaten breakfast and lunch on these days. Meza stated that R1 had requested a tray service to their room due to resident reporting feeling ill. LPA reviewed incident report dated 12/28/2022 where R1 was transferred out due to feeling ill. LPA reviewed dotor's note as the result of the visit stating that R1 should receivRead the full finding— CDSS inspection report, January 6, 2023 · control 18-AS-20221227143725

On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Memory Care Director Bobbie Rodgriguez and informed her of the purpose of today's inspection. Below is a summary of the findings of the investigation: Regarding allegation “Staff did not prevent resident from wandering away from the facility”: LPA Colvin interviewed staff and witnesses related to the event as well as reviewed the facility’s file for prior resident (R1). LPA Colvin confirmed that on 4/4/22, R1 eloped from the facility without staff knowledge by unfastening a screw from their window and then scaling a low wall. While the facility’s Special Incident Report (SIR) to Licensing states that staff became aware of the elopement within 45 minutes of R1’s departure from the facility, the facility’s internal report shows that staff noted the absence at 2:54pm and last observed R1 in the facRead the full finding— CDSS inspection report, August 23, 2022 · control 18-AS-20220818172214

On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Administrator Patrick Mcadoo Morton and Memory Care Director Bobbie Rodgriguez. Below is a summary of the findings of the investigation: Regarding allegation "Facility did not provide a safe environment for resident's in care": LPA Colvin interviewed staff and relevant parties as well as reviewed the facility's file and documents for resident (R1). LPA Colvin confirmed through record review and interviews that R1 began exhibiting increased aggressive behavior towards staff and residents two months prior (6/8/22), which included hitting, kicking, and spitting. While Administrator and Memory Care Director state that they reached out to R1's Public Guardian and doctor for assistance, the facility otherwise failed to act to protect the other residents until 7/1/22 when R1 was placed on a psychiatricRead the full finding— CDSS inspection report, July 14, 2022 · control 18-AS-20220706102318

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to Administrator, Patrick McAdoo-Morton, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with staff and residents. In regards to allegation #1, LPA Williams interviewed Staff # (S1) and Staff #2 (S2) who both stated that Resident #1 (R1) had pressure injuries while residing at the facility. S1 stated that they believe the pressure injuries were in Stage 1, while S2 stated that they were unaware of which stage R1's pressure injuries were in. Both S1 and S2 stated that R1's pressure injuries were being cared for by a home health agency, who came to the facility twice a week. S1 stated that R1 was sent to the emergency room, and consequently a skilled nursing facility, several times due to the worsening of R1's pressure injuries. LPA Williams interRead the full finding— CDSS inspection report, January 24, 2022 · control 18-AS-20200917115303