<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804058
Report Date: 05/02/2022
Date Signed: 05/03/2022 10:07:41 AM


Document Has Been Signed on 05/03/2022 10:07 AM - 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:WINDSONG OF SONOMAFACILITY NUMBER:
496804058
ADMINISTRATOR:SAVOIE, DEBORAHFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRIVETELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: DATE:
05/02/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
02:17 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This report is corrected for Collette Gray's title only.
COMP II by CAB successfully completed
Facility Type: RCFE
Application Type: CHOW
Capacity: 95
Census (if any clients in care): TBD
Method: Telephone call with CAB
COMP II Participants: Deborah Savoie, Administrator; Collette Gray, President/CEO; Shannon Betker, analyst.

Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming date of birth. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Staff training
4. Applicant and Administrator qualifications
5. Grievances, Complaints, Community resources
6. Food service
7. Medication management
8. Application document review and technical assistance: Pre-licensing inspection
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Shannon BetkerTELEPHONE: (916) 651-3018
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1