Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated, indicating generally good compliance over time. However, some complaints were substantiated, primarily involving issues with timely medical care and resident rights, including an unlawful eviction without proper notice in April 2025. The facility also had earlier deficiencies related to staff training, medication errors, and an elopement incident reported in May 2024. The most recent reports from July 30, 2025, cited deficiencies for not seeking timely medical care and wrongful eviction, with a civil penalty under review. While there is a pattern of some serious concerns around resident care and rights, recent investigations continue to address these issues, showing ongoing regulatory attention.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
70% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 1
Date: Jul 30, 2025
Visit Reason
The visit was an office meeting held to address areas of concern identified by the Department, specifically regarding personal rights/wrongful evictions and seeking timely medical care for residents.
Complaint Details
Deficiencies were cited on Complaint Control Number 21-AS-20250415140750. The issuance of a civil penalty is under review based on the complaint regarding timely medical care.
Findings
The report indicates that deficiencies were cited related to the facility not seeking timely medical care for a resident, and the issuance of a civil penalty is under review based on these violations.
Deficiencies (1)
Facility not seeking timely medical care for a resident as defined in Title 22, Division 6, Chapter 8, Article 08, Resident Assessments, Fundamental Services and Rights, 87469 Advanced Directives and Requests Regarding Resuscitative Measures
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Executive Director | Met with during the office meeting and named in the report. |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager and present at the meeting. |
| Robert Frank | Licensing Program Analyst | Named as Licensing Program Analyst. |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 1
Date: Jul 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation received on 2025-04-15 regarding an unlawful eviction of a resident who was denied the ability to return to the facility after a hospital visit.
Complaint Details
The complaint alleged unlawful eviction of resident R1 who was sent to the hospital on 2025-04-11 and denied return to the facility without a 30-day eviction notice or approval for a 3-day notice. The allegation was substantiated based on interviews, record review, and evidence.
Findings
The investigation substantiated that the facility did not comply with regulations by denying resident R1 the ability to return after a hospital emergency room visit without providing the required eviction notice or approval. The resident's behaviors were known and documented upon admission, and the denial posed an immediate health, safety, or personal rights risk.
Deficiencies (1)
Facility did not comply with CCR 87468.2(a)(20) by involuntarily evicting resident R1 without proper notice or approval after a hospital visit.
Report Facts
Capacity: 80
Deficiency due date: Jul 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Executive Director | Interviewed regarding denial of resident return and named in findings |
| Robert Frank | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 3
Date: May 30, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 2025-02-05 regarding failure to seek timely medical care, inadequate room cleanliness, lack of explanation of services, and failure to provide itemization of charges to residents' responsible persons.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to seek timely medical care for a resident who fell and sustained a head injury, failure to maintain cleanliness of a resident's room, and failure to provide explanation and itemization of charges related to a new level of care to the resident's responsible party. The facility delayed sending the resident to the hospital for nearly two hours and waited for hospice to make the decision. The responsible party was not timely notified of rate increases as required.
Findings
The investigation substantiated all allegations: the facility delayed sending a resident with a head injury to the hospital, failed to properly clean a resident's room, and did not provide timely written notification or itemization of charges related to a change in level of care to the responsible party. Deficiencies were cited under California Code of Regulations Title 22 and Health and Safety Code.
Deficiencies (3)
Facility did not immediately telephone emergency response for a terminally ill resident experiencing a life-threatening emergency unrelated to expected course of terminal illness.
Facility did not properly clean resident R2's room, leaving remnants of fecal incontinence unattended.
Facility failed to provide resident's responsible party written notice of rate increase within two business days after initially providing services at the new level of care.
Report Facts
Facility capacity: 80
Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeannette Kinney | Administrator | Facility administrator met during investigation and named in findings |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 0
Date: May 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not dispense medications as prescribed.
Complaint Details
The complaint alleged that medications were not dispensed as prescribed to a resident discharged to the facility. The investigation reviewed staffing schedules, medication administration records, and agreements with the pharmacy. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found a delay in a resident receiving new medications prescribed at discharge due to unclear adherence to facility protocol and absence of the Health and Wellness Director. However, there was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Report Facts
Facility capacity: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeanette Kinney | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 56
Capacity: 80
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
The inspection was an unannounced 1-Year Required annual inspection of the Brookdale Windsor Assisted Living facility to assess compliance with licensing requirements.
Findings
The facility was found to be clean, orderly, and compliant with regulations including fire safety, emergency preparedness, staff training, and resident care documentation. No deficiencies were cited during the visit.
Report Facts
Residents in care: 56
Total capacity: 80
Staff file sample size: 6
Resident file sample size: 6
Medication spot check sample size: 5
Fire extinguisher service date: Oct 9, 2024
Smoke and CO detector inspection date: Mar 5, 2025
Last disaster drill date: Feb 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Kinney | Executive Director/Administrator | Met during inspection; named in relation to facility administration and certification |
| Robert Frank | Licensing Program Analyst | Conducted the inspection |
| Dynine Lesley | Dining Room Director | Greeted Licensing Program Analyst upon arrival |
| Tina Worden | Health and Wellness Director | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 0
Date: Nov 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-08-12 regarding staff not ensuring a resident was free of scabies and staff neglect resulting in a resident sustaining a pressure injury.
Complaint Details
The complaint was unsubstantiated. Allegations included staff failing to ensure a resident was free of scabies and neglect causing a pressure injury. Investigations included review of medical records, incident reports, hospital discharge papers, and observations. No preponderance of evidence was found to prove the alleged violations.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident refused most scheduled showers, limiting staff's ability to observe skin for scabies. Hospital discharge papers did not mention scabies. The alleged pressure injury was not observed to be a pressure wound, and charting notes did not reflect pressure wounds. Therefore, both allegations were unsubstantiated.
Report Facts
Facility capacity: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Administrator | Met with Licensing Program Analyst during investigation |
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 80
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-04-26 regarding the facility's care and operations.
Complaint Details
The complaint investigation addressed nine allegations including failure to provide daily activities, not following the admission agreement, sharing confidential information without authorization, forcing memory testing without consent, inadequate feeding, violation of personal rights, failure to safeguard personal items, and not seeking timely medical attention. All allegations were found unsubstantiated after review of care notes, interviews, and policy documents.
Findings
The investigation found no preponderance of evidence to substantiate any of the nine allegations, including issues related to daily activities, admission agreement compliance, confidentiality breaches, forced memory testing, adequate feeding, personal rights, safeguarding personal items, and timely medical attention. The report concluded all allegations as unsubstantiated and cited no deficiencies.
Report Facts
Capacity: 80
Census: 59
Complaint Control Number: 21-AS-20240426155018
Meal refusals: 70
Weight measurements: 116.8
Weight measurements: 129
Care conferences: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Kinney | Administrator | Met with Licensing Program Analyst during investigation |
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 57
Capacity: 80
Deficiencies: 5
Date: May 30, 2024
Visit Reason
The inspection was a required unannounced annual inspection conducted to evaluate compliance with licensing regulations and facility standards.
Findings
The facility was generally clean and well-maintained with proper food storage issues noted. Several deficiencies were cited related to staff training, health screenings, and medication administration errors. An elopement incident was reported and addressed with corrective actions.
Deficiencies (5)
Staff S1, S2, S3, S4, and S5 did not have current First Aid/CPR certification.
Resident R2 received medication not prescribed to them, indicating a medication error.
Staff S1, S2, S3, S4, and S5 did not have health screenings on file.
Resident R1 eloped from the facility, posing a potential safety risk.
Staff S1, S2, S3, S4, and S5 did not have training records available.
Report Facts
Census: 57
Total Capacity: 80
Deficiencies cited: 5
Medication monitoring period: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Administrator | Named as facility administrator with certificate expiring 8/12/2024 |
| Tina Wolden | Health and Wellness Director | Facility contact with signing permissions and involved in incident management and training |
| Christi Coppo | Licensing Program Analyst | Conducted inspection and signed report |
| Jacqueline Macias | Licensing Program Analyst | Conducted inspection |
| Victoria Bertozzi | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 80
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-17 regarding resident care issues including development of a pressure injury, failure to follow doctor's orders, and failure to provide dry linen.
Complaint Details
The complaint alleged that a resident developed a pressure injury that was not observed or reported by staff, that staff failed to follow doctor's orders for wound care resulting in cellulitis infection, and that staff did not provide dry linen causing the resident's foot to be on a wet surface. The investigation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. The department was unable to determine if staff observed and reported the pressure injury, followed doctor's wound care orders, or provided dry linen as alleged. No deficiencies were cited during the visit.
Report Facts
Capacity: 80
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Oversaw the complaint investigation |
| Tina Worden | Health and Wellness Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 80
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on self-reported incidents of possible financial abuse involving residents.
Complaint Details
The visit followed up on two SOC-341 reports received on 12/08/2023 and 01/02/2024 regarding suspected financial abuse involving missing money and items from Resident 1 and Resident 2. The facility found $140 missing from Resident 1 on 12/08/2023 and $1700 missing approximately 3 months prior. Resident 2 was reported missing $580, a bag of jewelry, and a blanket as of 12/28/2023. The facility communicated with responsible parties and planned a Town Hall meeting to address theft prevention.
Findings
The facility reported two incidents of suspected financial abuse involving missing money and items from residents' rooms. The facility made all appropriate notifications and communicated with responsible parties. No deficiencies were cited during the visit.
Report Facts
Missing money amount: 140
Missing money amount: 1700
Missing money amount: 580
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Worden | Health and Wellness Director | Met with Licensing Program Analyst during the visit |
| Caitlynn Felias | Licensing Program Analyst | Conducted the Case Management - Incident visit |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 80
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as a Case Management follow-up regarding a self-reported incident where a staff allegedly violated the personal rights of a resident in care.
Complaint Details
The visit was complaint-related due to a self-reported incident alleging violation of a resident's personal rights. The facility is investigating internally and has cross-reported the incident as required. The Licensing Program Analyst is following up and gathering more information.
Findings
The Licensing Program Analyst conducted interviews and is obtaining additional information. The facility is conducting an internal investigation and the involved staff is on leave. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Administrator | Met with Licensing Program Analyst during the inspection and provided information about the internal investigation. |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the Case Management inspection and interviews. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 80
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The inspection was an unannounced case management visit to follow up on self-reported incidents involving two residents, including a positive COVID diagnosis and a fall resulting in injury and death.
Complaint Details
The visit was triggered by self-reported incidents involving two residents: one hospitalized after a positive COVID diagnosis and another who fell, suffered injuries, and later died. The resident did not require one-to-one supervision per their care plan.
Findings
The inspection reviewed resident files and care plans related to the incidents. One resident was hospitalized due to COVID and other health concerns, and another resident suffered a fall causing a head laceration and fracture, later passing away. The care plans were found to document relevant health concerns and supervision needs.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Administrator | Met with Licensing Program Analysts during the inspection. |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the case management inspection. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 42
Capacity: 80
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
The inspection was an unannounced Case Management visit conducted to review reports regarding a resident who was recently discharged from hospice services and had an incident involving a fall.
Findings
No deficiencies were cited during this inspection. The resident was found on the floor by staff, denied pain initially, later complained of pain and was transported to the hospital where they passed away three days later. The resident did not require 1:1 supervision per file review.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandee Rodriguez | Administrator | Met with Licensing Program Analyst during the Case Management inspection. |
Inspection Report
Annual Inspection
Census: 47
Capacity: 80
Deficiencies: 0
Date: May 5, 2023
Visit Reason
An unannounced annual required inspection was conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be in compliance with regulations, with no deficiencies cited. Observations included appropriate water temperatures, secured medications, proper storage of food and cleaning supplies, and up-to-date fire safety equipment and drills.
Report Facts
Water temperature readings: 108
Water temperature readings: 111
Water temperature readings: 112
Water temperature readings: 113
Water temperature readings: 114
Facility capacity: 80
Resident census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandee Rodriguez | Administrator | Administrator during inspection; certificate expires 7/12/2023 |
| Don Rodreick | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the annual inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 80
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
The inspection was an unannounced Case Management visit to follow up on three incidents involving residents, including two incidents between residents R1 and R2 and a third incident involving resident R3's injury during a transfer.
Complaint Details
The visit was complaint-related, following up on three incidents: two involving residents R1 and R2 with behavioral issues and one involving resident R3 who sustained a leg break during a transfer. The complaint was investigated with review of care plans, staff training, and physician reports. No deficiencies were cited.
Findings
The inspection found no deficiencies. The incidents involved resident interactions and an injury requiring hospital transport, with appropriate follow-up actions taken by the facility and consultation with responsible parties.
Report Facts
Incidents followed up: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Watson | Administrator | Met with Licensing Program Analyst during inspection and involved in incident follow-up |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the unannounced Case Management inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 80
Deficiencies: 0
Date: Oct 21, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including questionable deaths, failure to seek timely medical attention for residents, and failure to report incidents involving residents.
Complaint Details
Complaint alleged multiple residents died after ingesting chemicals instead of juice, staff delayed calling emergency services for 1.5 hours, and incidents were not reported to licensing. The complaint was found to be unfounded.
Findings
The investigation found the complaint to be unfounded after interviews, observations, and document reviews. Evidence did not support the alleged incident of residents ingesting chemicals, and staff denied the occurrence. Police logs showed no response to such an incident, and resident death reports did not indicate chemical ingestion.
Report Facts
Facility capacity: 80
Resident census: 51
Complaint receipt date: Oct 3, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Wendy Watson | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 52
Capacity: 80
Deficiencies: 0
Date: Apr 22, 2022
Visit Reason
The inspection was an unannounced Annual Required inspection focused on the Infection Control procedures and practices of the facility.
Findings
The facility maintained infection control measures including hand sanitizer stations, mask requirements for staff, and signage for residents. The facility had no deficiencies cited during this inspection and maintained adequate supplies of PPE and medication. Discussions included visitation policies, emergency disaster plans, and infection control plans.
Report Facts
PPE supply duration: 30
Medication supply duration: 30
Fire extinguisher last serviced: 2021
Fire alarm system last serviced: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Watson | Administrator | Met with Licensing Program Analyst during inspection and discussed facility policies and infection control. |
| Victoria Willis | Licensing Program Analyst | Conducted the unannounced annual inspection focused on infection control. |
| Hope DeBenedetti | Licensing Program Manager | Named in report header and signature section. |
Inspection Report
Census: 55
Capacity: 80
Deficiencies: 0
Date: Feb 8, 2022
Visit Reason
The inspection was an unannounced Case Management visit to follow up on two self-reported incidents involving residents who had un-witnessed falls resulting in injuries.
Findings
No deficiencies were cited during this inspection. Both residents involved in the incidents did not require one-to-one assistance and were receiving appropriate follow-up care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Watson | Administrator | Met with Licensing Program Analyst during inspection and mentioned in relation to incident follow-up. |
| Victoria Willis | Licensing Program Analyst | Conducted the unannounced Case Management inspection. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 58
Capacity: 80
Deficiencies: 0
Date: May 25, 2021
Visit Reason
The inspection was an unannounced Annual Required inspection focused on the Infection Control procedures and practices of the facility.
Findings
The facility demonstrated compliance with infection control practices including use of hand sanitizer, mask wearing by staff, social distancing in dining and common areas, PPE training and fit testing, and approved Covid Mitigation Plan. No deficiencies were cited during this inspection.
Report Facts
Percentage of residents allowed to dine at a time: 25
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Watson | Administrator | Met with Licensing Program Analyst during inspection and discussed infection control and emergency disaster plan. |
| Victoria Willis | Licensing Program Analyst | Conducted the inspection and met with the Administrator. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 0
Date: Mar 17, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility was in disrepair.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.
Findings
The investigation found the complaint to be unfounded, with no evidence of disrepair or issues. The city water department inspected the water supply and found no problems. No citations were issued.
Report Facts
Facility capacity: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Watson | Executive Director | Interviewed during the complaint investigation |
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 80
Deficiencies: 1
Date: Feb 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging the facility failed to readmit a resident in a timely manner upon discharge from the hospital and alleged insufficient staffing.
Complaint Details
The complaint was substantiated regarding failure to readmit a resident timely after hospital discharge. The allegation of insufficient staffing was unsubstantiated and dismissed.
Findings
The complaint that the facility failed to readmit a resident in a timely manner was substantiated, with evidence showing Covid positive residents were transferred to skilled nursing or designated Covid facilities regardless of symptoms. The allegation of insufficient staffing was unsubstantiated and dismissed. No deficiencies were cited for staffing.
Deficiencies (1)
Facility failed to protect residents from involuntary transfers and discharges in violation of state laws and regulations by transferring Covid positive residents regardless of symptoms.
Report Facts
Capacity: 80
Census: 49
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Willis | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Wendy Watson | Administrator | Facility administrator involved in investigation and findings |
| Hope DeBenedetti | Licensing Program Manager | Oversaw complaint investigation |
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