Inspection Report Summary
Most inspections found deficiencies related primarily to environment and resident rights, with issues such as unlocked hazardous materials accessible to residents and a staff member restricting a resident’s television use without permission. Several complaint investigations were conducted, with some allegations substantiated and others unsubstantiated. The most recent report from March 18, 2025, showed no deficiencies, indicating improvement since earlier findings. Earlier annual inspections cited concerns including incomplete staff training, emergency drill documentation gaps, and safety equipment problems. No fines, enforcement actions, or severe harm-level findings were noted in the available reports.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Mar 18, 2025
Visit Reason
Licensing Program Analysts conducted a Required-1 Year unannounced visit to evaluate the facility's compliance with licensing regulations and operational plans.
Findings
The facility was found to be in compliance with all regulatory requirements, including approved dementia and hospice plans, infection control, emergency preparedness, and safety measures. No deficiencies were cited during the inspection.
Report Facts
Staff on duty: 3
Resident files reviewed: 6
Staff files reviewed: 5
Hot water temperature: 116
Emergency disaster drills: 2
Documents requested for update: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bana Solomon | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Ana | Lead Caregiver | Staff on duty during inspection. |
| Roxanna | Caregiver | Staff on duty during inspection. |
| Yadira | Caregiver | Staff on duty during inspection. |
| Dina Alviso | Licensing Program Analyst | Conducted the inspection. |
| Bethany Moellers | Licensing Program Manager | Oversaw the inspection process. |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 2
Jan 31, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that residents were not served adequate portions of food and that hazards were accessible to residents in care.
Findings
The allegation regarding inadequate food portions was found to be unfounded after interviews and observations. However, the allegation that hazards were accessible to residents was substantiated, with deficiencies cited for unlocked medication closet and garage door leaving hazardous items accessible.
Complaint Details
The complaint investigation was triggered by allegations that residents were not served adequate portions of food and that hazards were accessible to residents. The food portion allegation was found to be unfounded, while the hazards allegation was substantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication closet was observed unlocked, and all medications were accessible to residents in care. | Type A |
| Door leading into the garage was unlocked, leaving disinfectants, soaps, cleaners accessible to residents in care. | Type A |
Report Facts
Capacity: 6
Census: 5
Deficiencies cited: 2
Plan of Correction Due Date: Feb 1, 2025
Proof of Training Due Date: Feb 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bana Solomon | Administrator | Met with Licensing Program Analyst during inspection and named in findings |
| Ana Herron | Caregiver | On shift during inspection and signed report for Administrator |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
Jan 9, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not allow a resident to watch television and that staff yelled at residents and did not treat them with respect.
Findings
The allegation that staff did not allow a resident to watch television was substantiated, as a staff member had put a resident's television on a timer to shut off without the resident's permission. The allegations that staff yelled at residents and did not treat them with respect were unsubstantiated based on interviews and observations.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not allow a resident to watch television, citing violation of California Code of Regulations 87468.2(a)(6). The allegations that staff yelled at residents and did not treat residents with respect were unsubstantiated due to insufficient evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff put a resident's television on a timer to shut off at a specific time in the evening without the resident's permission, violating personal rights. | Type B |
Report Facts
Capacity: 6
Census: 6
Deficiencies cited: 1
Plan of Correction Due Date: Jan 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bana Solomon | Administrator | Met with Licensing Program Analyst during inspection and named in findings |
| Dina Alviso | Licensing Program Analyst | Conducted complaint investigation |
| Bethany Moellers | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 7
Apr 16, 2024
Visit Reason
The inspection was a Required - 1 Year unannounced visit to evaluate compliance with licensing regulations for the Windrose Care Home facility.
Findings
The facility was found to have several deficiencies including unlocked storage of cleaning supplies accessible to residents, incomplete staff training hours, lack of documentation for quarterly emergency drills, a leaking pipe under a resident bathroom sink, missing 'Oxygen in Use' signage, and malfunctioning auditory alarms on exit doors. Plans of correction were requested with specific due dates.
Severity Breakdown
Type A: 2
Type B: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Garage door was not locked, leaving cleaners, soaps, disinfectants accessible to residents. | Type A |
| Staff lacked completed required medication training hours for those handling medications. | Type A |
| Five staff out of five lacked completed initial 40-hour required care staff training. | Type B |
| No documentation of quarterly emergency drills being conducted on every shift as required. | Type B |
| Resident bathroom sink had a leaking pipe underneath. | Type B |
| Facility did not have required 'Oxygen in Use' signage posted where oxygen is used. | Type B |
| Front door and slider patio door auditory alarms were not working properly. | Type B |
Report Facts
Residents in care: 4
Total licensed capacity: 6
Staff lacking 40-hour training: 5
Staff lacking medication training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bana Solomon | Administrator | Met with Licensing Program Analysts during inspection |
| Ana Herron | Lead Caregiver | Named in exit interview and appeal rights given |
| Dina Alviso | Licensing Program Analyst | Conducted inspection and authored report |
| Carla Martinez | Supervisor | Supervisor overseeing inspection |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Original Licensing
Capacity: 6
Deficiencies: 0
Apr 4, 2023
Visit Reason
The inspection was a pre-licensing visit conducted to evaluate the facility prior to licensing and to verify compliance with regulatory requirements.
Findings
The inspection found that the facility met all required conditions for licensing, including fire clearance, approved hospice and dementia plans, secured storage for medications and toxins, and no observed health or safety hazards during the visit.
Report Facts
Facility capacity: 6
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bana Solomon | Applicant and future Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Dina Alviso | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header and signature |
Inspection Report
Original Licensing
Capacity: 6
Deficiencies: 8
Mar 21, 2023
Visit Reason
Prelicensing inspection conducted to evaluate the facility for initial licensing and compliance with regulatory requirements.
Findings
The facility was found to be generally compliant with fire safety, infection control, and resident safety requirements, with some outstanding items such as installation of railings on the front door ramp, locking mechanisms for medications, knives, and cleaning supplies, and repair of a fire door that did not close properly. The applicant will complete these items and schedule a follow-up inspection.
Deficiencies (8)
| Description |
|---|
| Front door ramp railings need to be installed. |
| Applicant to install gate or railing at two steps dropping from side of resident room. |
| Locking mechanism to be installed for medication storage to ensure inaccessibility to residents. |
| Locking mechanism to be installed for knife storage in kitchen to ensure inaccessibility to residents. |
| Fire door in the home did not close when activated and needs to be checked and repaired. |
| Locking mechanism to be installed on cabinet for disinfectant cleaners/toxins for staff use. |
| Applicant to post all required documents as discussed. |
| Ensure sufficient lighting in resident rooms such as lamps for night stands. |
Report Facts
Facility capacity: 6
Census: 0
Inspection start time: 855
Inspection end time: 1235
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bana Solomon | Applicant and designated Administrator | Met during prelicensing inspection and responsible for facility compliance |
| Dina Alviso | Licensing Program Analyst | Conducted the prelicensing inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Capacity: 6
Deficiencies: 0
May 17, 2022
Visit Reason
Initial licensing evaluation of Windrose Care Home Facility to assess compliance with licensing requirements and applicant/administrator qualifications.
Findings
The applicant/administrator participated in a telephone call to confirm understanding of facility operation, staff qualifications, program policies, and application document requirements. The Component II evaluation was successfully completed with no clients currently in care.
Report Facts
Capacity: 6
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bana Solomon | Applicant/Administrator | Participated in licensing evaluation and telephone call confirming understanding of licensing requirements |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on report |
| Victoria Christiansen | Licensing Program Analyst | Named as Licensing Program Analyst on report |
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