Facility Evaluation Report

At approximately 8:35 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection and was greeted by Dinning Room Director, Dynine Lesley. Health and Wellness Director (HWD) Tina Worden arrived at 9:50 AM. Executive Director (ED) Jeanette Kinney arrived at 10:30 AM from a previously scheduled appointment. Brookdale Windsor serves older adults in Assisted Living. The Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for eighty (80) non-ambulatory residents. Facility has an approved hospice waiver for ten (10) residents. The facility is a multi-level building with a large patio and garden area between the two (2) resident wings. Upon arrival, LPA was informed that there were fifty-six (56) Residents in care. At approximately 10:00 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation.

At approximately 10:45 AM LPA toured the facility with HWD Worden . The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a variety of menu options for the residents at each meal. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of six (6) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. All stairwells had evacuation chairs per regulation.