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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803772
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:07:55 PM

Document Has Been Signed on 09/23/2022 12:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WINDSONGFACILITY NUMBER:
126803772
ADMINISTRATOR:CECIL P. WILSON IIIFACILITY TYPE:
735
ADDRESS:500 SILER LANE UNIT BTELEPHONE:
(707) 798-6319
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 25CENSUS: 23DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kim JohnsonTIME COMPLETED:
12:15 PM
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At approximately 10:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to several unusual incident reports submitted to CCL. LPA met with Administrator Kim Johnson, toured the facility and reviewed records.
#1: During medication administration, a medication was dropped and became unusable. LPA reviewed medication procedures with Administrator and found the facility policy was within regulation.
#2: Staff were knocking on the door to Clients room and there was no response. After several attempts, staff used the master key to enter the room to ensure the safety of the client. Upon entry, Client was found to be safe. Client was upset with staff and was ignoring them was the reason given for not opening the door. Client accused staff of sexual abuse because they used the key to enter the room. Staff informed client that they entered because there was no answer and they feared for the safety of the client.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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