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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804058
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:59:08 PM

Substantiated


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
11/02/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20221102092137
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: 111DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator Deborah SavoieTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Uncleared adults providing care to residents
INVESTIGATION FINDINGS:
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On 11/17/2022 LPA Hansen arrived unnanounced to facility to continue investigation into complaints. LPA made note of log in sheet at counter.

Based on Record Review 6 out of 6 agency staff were not associated to facility and 3 our of 6 agency staff were not background cleared. Unassociated staff left the facility at the time of the visit.
Allegation is SUBSTANTIATED and Civil Penalties are being assessed for $100 per staff. The preponderance of evidence standard has been met: therefore, the above allegation is found to be Substantiated.

Immediate Civil Penalties are being assessed in the amount of $600 due to staff S1, S2, S3, not having background check clearance and staff S1, S2, S3, S4, S5, and S6 not being associated to the facility.

*****Total Civil Penalties issued today in the amount of $600.00

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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20221102092137
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: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
CCR
87355(e)(1)
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 All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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Administrator agrees to send in written plan of correction that they understand all staff must be fingerprint cleared and associated prior to working in the facility. POC due date of 11/18/2022.
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Based on observation and record review Administrator didn't comply w/section cited above in 3 out of 6 staff did not have the proper fingerprint clearance and 6 our of 6 staff were not associated to the facility.
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 Due to Administrators failute to have S1 -S3 fingerprint cleared and S1-S6 associated to the facility Civil Penalties are being issued today in the amount of $600.00.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
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