Facility Evaluation Report

At approximately 9:05 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year inspection and was greeted by Administrator Gachu and staff member Darcy Harlan. Windsor House is Licensed as an Adult Residential Facility (ARF). The facility is a single story ranch house. The facility has an approved fire clearance for four (4) ambulatory Clients between the ages of eighteen (18) and fifty-nine (59). Upon arrival, LPA was informed that there were two (2) clients in care and two (2) staff members on-site. At approximately 9:20 AM, LPA reviewed the Facility's Staff Roster and observed that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:30 AM, LPA toured the facility with Administrator Gachu. All exits were clear and unobstructed. All three (3) fire extinguishers were last serviced and tagged in 10/2024. Food supply was sufficient. The facility was sufficiently lighted with the exception of the kitchen area as the LED light was not working. LPA inspected two (2) client bedrooms and observed all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored inaccessible to clients. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted in 9/2025. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were observed to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. LPA observed that window screens were not present in two of the facility’s front windows. One of these windows was open during the inspection. This deficiency will be cited.