The Windham

Type of visit: Required - 1 Year

On 05/21/2026, Licensing Program Analyst (LPA) M Vega arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director - John Earley. LPA conducted tour inside and out of facility with ED. Residents were observed throughout the facility. A sample of residents’ file was reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. The facility was observed to be at a comfortable temperature of 70 to 75 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 11/11/2025 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week, on Tuesdays and Fridays. Refrigerator temperature was maintained at 42.0 degree F. and freezer was maintained, Temperature in facility ranged from 82 degrees to about 68 degrees. LPA toured a sample of resident bedrooms. Residents' rooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Water temperature tested in room 104 at 116.6 Degrees F, room 110 at 117.1 Degrees F, room 265 at 115.3 Degrees F and room 272 at 112.6 Degrees F. Continuation on LIC 809C Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Pool operational, gated and gate locked for residents’ safety. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate and up to date information for your facility. In an effort to maintain your facility file, please submit the most current and complete forms and/or information as identified below: Residential Care Facility for the Elderly (RCFE) LIC 308 Designation of Facility Responsibility LIC 309 Administrative Organization LIC 400 Affidavit Regarding Client/Resident Cash Resources LIC 402 Surety Bond LIC 500 Personnel Report LIC 610E Emergency And Disaster Plan For Residential Care Facilities For The Elderly LIC 9020 Register of Facility Clients/Residents Copy of current Liability Insurance Copy of current Administrator Certificate Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 06/04/2026 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the ED A copy of this report was given to ED whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, May 21, 2026

Type of visit: Case Management - Other

On 12/12/2025 Licensing Program Analyst (LPA) M Vega arrived at the facility unannounced to conduct a case management. LPA entered the facility, introduced self, and explained the reason for the visit. LPA met with Executive Director - John Earley. LPA collected documents from R1, MAR/centrally stored January and February 2025. Exit interview was conducted and a copy of this report LIC 809 was provided to John Earley.the state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Required - 1 Year

On 06/27/2025, Licensing Program Analyst (LPA) M Vega arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director - John Earley. LPA conducted tour inside and out of facility with ED. Residents were observed at the facility during lunch. The facility was observed to be at a comfortable temperature of 67 to 80 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 11/26/2024 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week, on Tuesdays and Fridays. Refrigerator temperature was maintained at 42.0 degree F. and freezer was maintained, Temperature in facility ranged from 82 degrees to about 68 degrees. LPA toured a sample of resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Water temperature tested in room 261 at 114.9 Degrees F, and room 264 at 117.1 Degrees F. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured laundry room and observed chemicals were stored and locked. Continued on LIC 809C Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Pool operational, gated and gate locked for residents safety. A sample of residents’ file was reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate and up to date information for your facility. In an effort to maintain your facility file, please submit the most current and complete forms and or information as identified below: Residential Care Facility for the Elderly (RCFE): LIC 308 Designation of Facility Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly LIC 9020 Register of Facility Clients/Residents Copy of current Liability Insurance Copy of current Administrator Certificate Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 07/03/2025 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the ED A copy of this report was given to ED whose signature on this form confirm receipt of these reports.the state’s words, verbatim · CDSS document, Jun 27, 2025

Type of visit: Office

An Informal Meeting was held via Teams on 12/23/2024. The purpose of the office meeting was to discuss recently identified issues associated with the operation of the facility. The informal conference process was explained during the meeting. The following were in attendance: CCLD Brenda Chan – Licensing Program Manager Martin Vega – Licensing Program Analyst The Windham John Earley – Executive Director / Administrator Leticia Higares – Regional VP of Operations Nancy Pultz – Health and Wellness Director Kimberly Eldridge – Regional Health and Wellness Director During this meeting the following issues were brought to the attention of the licensee: Type A 11/22/24 Section Cited CCR 87705 - Care of Persons with Dementia Type A 04/03/24 Section Cited CCR 87465 - Incidental Medical and Dental Care Licensee has agreed to provide a Plan of Action, describing how to maintain the health and safety of facility residents, to CCLD by 12/27/2024. Continued on LIC 809C The Administrator agreed to do the following: Executive Director (ED) stated that will update medical forms for residents. All facility staff will be trained in appropriate management of residents that present wondering tendencies and Dementia Diagnoses. ED stated that implemented training to staff regarding medication distribution to residents. An exit interview was conducted, and a copy of this report dated was given to ED on 12/23/2024, Licensing Program Manger Brenda Chan offered Executive Director John, information about Technical Support Program: https://cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/technical-support-program. ED stated that facility will not need TSP service at this time.the state’s words, verbatim · CDSS document, Dec 23, 2024

Allegation investigated: Staff did not properly supervise resident, resulting in death.

On 11/21/2024, Licensing Program Analyst (LPA) M Vega conducted an unannounced complaint inspection at 1540 hours. LPA met with Licensee John Earley. The purpose of this visit is to deliver the finding of the investigation completed by the Department. LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. On 08/16/2024, the Department received a report alleging that staff did not properly supervise resident, resulting in death. Continuation on LIC 9099C Unsubstantiated The Department conducted interviews and record reviews. On 07/22/2024, Resident (R1) was found deceased in an empty file adjacent to the facility. Local police department noted no foul play. Due to R1 dying of natural causes and R1’s history of disease, it cannot be determined that staff’s lack of care and supervision resulted in R1’s death. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is unsubstantiated, at this time. An exit interview was conducted, and a copy of this report dated 11/21/2024 along with appeal rights were provided to licensee. No deficiencies were cited during this visit.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 24-AS-20240816165008

Type of visit: Case Management - Deficiencies

On 11/21/2024, Licensing Program Analyst (LPA) M Vega conducted an unannounced case management at 1540 hours. LPA met with Health and Wellness Director Nancy Pultz. Licensee John Earley was contacted by phone and arrived a short moment after. The purpose of this visit is to deliver the finding of review completed by the Department. LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. On 08/16/2024, the Department received a complaint and conducted the investigation. During the course of investigation, it was discovered that staff failed to supervise resident (R1) while in care. On 07/22/2024, R1 was found deceased in an empty field adjacent to the facility. The last time staff saw R1 was at approximately 1600 hours. Staff failed to notify anyone until approximately 2115 hours. According to Physician’s Report, R1 was diagnosed with Dementia. R1 was not able to leave the facility without staff escort or supervision due to R1’s cognitive impairment. Staff admitted they never supervised R1 outside of the facility. Based on the review conducted by the Department and information gathered, the following deficiency was cited on LIC 809-D per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8. An immediate civil penalty of $500.00 was issued and a copy of the LIC 421IM was given to Licensee John Earley. At the time of the case management on 11/21/2024, licensee was informed that a future civil penalty may apply based on Health and Safety Code § 1569.49. An exit interview was conducted, and a copy of this report dated 11/21/2024, along with licensee. Appeal Rights (LIC 9058) was provided to Licensee John Earley whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Nov 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Nov 22, 2024

87705 CARE OF PERSONS WITH DEMENTIA 87705 (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident's physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident's behavior or condition changes. (2) Safety measures to address behaviors such as wandering,... materials.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Licensee stated that staff training on care of persons with dementia will be conducted on 11/21/2024. Licensee agrees to develop a written plan of correction (POC) describing in writing how facility shall ensure compliance with CCR 87705 and how similar incident related to violation will be prevented in the future for health and safety of residents. POC shall be received in licensing office by fax and/or mail by due date. Failure to meet POC due date may result in a civil penalty of $100 or more per day.

Type of visit: Case Management - Other

On 7/26/24 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management. LPA entered the facility, introduced herself, and explained the reason for the visit. LPA was not able to meet with Administrator John Earley at this time. LPA met with Nancy Pultz. LPA toured the facility to verify there was no immediate danger. LPA collected additional documents from R1's chart and documents from R2's chart. Exit interview was conducted and a copy of this report LIC809 was provided to Nancy Pultz.the state’s words, verbatim · CDSS document, Jul 26, 2024

Type of visit: Required - 1 Year

On 06/12/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Health and Wellness Director (HWD) Nancy Pultz. LPA conducted tour inside and out of facility with ED. Residents were observed at the facility during breakfast. The facility was observed to be at a comfortable temperature of 67 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 11/21/2023 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week, on Tuesdays and Fridays. Refrigerator temperature was maintained at 42.0-degree F. and freezer was maintained at 0-degree F. LPA toured a sample of resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested and observed with in regulation. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured laundry room and observed chemicals were stored and locked. Report continues on LIC809-C Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Pool operational, gated and gate locked for residents safety. A sample of residents’ file was reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · -as applicable: LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents · Copy of current Liability Insurance · Copy of current Administrator Certificate · Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 06/20/2024 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the HWD A copy of this report was given to HWD whose signature on this form confirm receipt of these reports.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) V Gorban conducted a Case Management visit. During this visit LPA met with facility the facility clerk Charles Flood and explained the purpose of the visit. Administrator (AD) John Earley was notified of Licensing visit and was able to attend it. Case Management visit was conducted based on the incident report occurred on 3/20/24 with R1. During this visit LPA conducted health and safety facility check and observed and interviewed R1 and R2. Based on facility records R1 received morning medications prepared for R2, which poses health and safety risk to residents in care. Cited violation attached on LIC809-D. Exit interview conducted, report signed and copy of this report with appeal rights provided to AD for facility records.the state’s words, verbatim · CDSS document, Apr 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 3, 2024

87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This was not observed as evidenced by Facility failed to administer medications as prescribed. R1 was provided medications prescribed for R2. This poses an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Apr 2, 2024

Plan of correction: FAcility Administrator will retrained med techs on how to administer medications to residents/ couple to avoid future errors. AD will provide staff training receipts on medication dispensing to LPA by email by 4/03/24