496804058-2-24-2023-21-AS-CMAZ-CPFUUB-20230227145317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804058
Report Date: 02/24/2023
Date Signed: 02/24/2023 10:45:36 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20221216150157

FACILITY NAME:	WINDSONG OF SONOMA		FACILITY NUMBER:	496804058
ADMINISTRATOR:	SAVOIE, DEBORAH		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DRIVE		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS:	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Deborah Savoie		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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9

Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegation. It has been alleged that facility has allowed visitors without masks to enter facility and that staff (S1) was allowed to work on or about 12/15/2022 after testing positive for Covid. During the course of this investigation statements were taken; documents reviewed, and site visits made. The following determinations are made: There are differing opinions regarding the allegation regarding Covid masking and no written documentation supporting the allegation was found; Management denies allowing staff to remain at facility with positive test; Staff # 2 does not verify the staff remaining at facility and potential Witness # 3 has not cooperated with investigation despite numerous attempts to obtain a statement from the witness. While the allegation may be true, based upon the statements taken and documents reviewed, there is not a preponderance of evidence to prove the allegation did or, did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Report left.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20221216150157

FACILITY NAME:	WINDSONG OF SONOMA		FACILITY NUMBER:	496804058
ADMINISTRATOR:	SAVOIE, DEBORAH		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DRIVE		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS:	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Deborah Savoie		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
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3
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5
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7
8
9

Facility failed to follow their Infection Control Plan

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering finding on this complaint. LPA met with the Administrator and discussed the allegation. During the course of this investigation statements were taken and documents reviewed, as well as site visits made. The Facility’s Infection Control Plan has been reviewed. The following determinations are made: There are differing opinions regarding whether or not protocols for masking and staff working with positive Covid test are followed; The facility’s Infectious Control Plan, signed by Administrator on 3/22/2022, provides minimum training and qualification requirements and specifies that the designated infection preventionist receive be a licensed professional or receive specified training from medical professionals; On or about 1/13/2023 at a meeting of Administration and CCL staff it was determined that the Preventionist had not had the required training. Therefore, based upon the statements and documents reviewed, the preponderance of evidence standard has been met and the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20221216150157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSONG OF SONOMA	FACILITY NUMBER: 496804058
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/28/2023 Section Cited CCR 87470(c)	1 2 3 4 5 6 7	87470© Infection Control Requirements. An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. ***Based on documents and statements, this requirement not met as evidenced by: Facility’s Infection Preventionist has not been trained in	1 2 3 4 5 6 7	Administrator shall review the requirements of 87470 and submit a dated and signed declaration indicating thorough knowledge of the requirements and commitment to follow those requirements going forward. Declaration to be submitted by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	accordance with the facility’s ICP. This poses an immediate risk to health of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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