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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804058
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:53:22 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
PUBLIC
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: 63DATE:
02/23/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Deborah Savoie, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not trained
Residents are not receiving bath/showers regularly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator Deborah Savoie.

Staff are not trained – Complainant alleges there are staff giving medications and are not trained appropriately. Based on a review of 8 staff training records as of February 22, 2023, and LIC 500 RCC noted on “Med Aide not having medication training completed”, 5 out 8 staff (S1, S2, S3, S4, & S5) who assist in the administration of medications do not have the required training within the last 12 months Per Health And Safety Code 1569.69. LPA conducted interviews and was informed by RCC that S1-S5 pass out medications to residents and have not completed required training. Facility provided staffing schedules for the months of January & February 2023 and it was revealed that S1 - S4 have passed out medications to residents.
Based on records review and interviews conducted with staff, the preponderance of evidence standard has been met, therefore the above allegation of staff giving medications are not trained appropriately is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D.
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: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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 5
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
VISIT DATE: 02/23/2023
NARRATIVE
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Residents are not receiving bath/showers regularly- Complainant alleges staff are not giving residents baths or showers and 17 days had passed since receiving a bath or shower. LPA obtained R1’s personal logging of showers given, showing staff had not given a shower in 17 days (9/17/2022 - 10/4/2022) and 14 days (10/10/2022 - 10/26/2022). R1’s Care plan indicates resident is to receive two to three showers or baths per week. LPA conducted interviews with staff on 1/19/2023, based on interviews with staff (S1) residents were not getting showers in 9/2022 & 10/2022 because there was a lot of agency staff who did not know how to give showers, and the facility does not keep shower logs. Staff also informed there were multiple complaints from responsible parties that showers were not being given. Facility was previously cited in complaint 21-AS-20220902140830 on 12/2/2022 for same violation, making this a repeat within the a 12 month period. The preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

**Civil Penalty are issued today in the amount of $250 for a repeated violation within a 12 month period.

Appeal of Rights Given.



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

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited
HSC
1569.69(b)
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HSC1569.69 (b) Each employee who received training ... required & continues to assist with the self-administration of medicines, shall also complete 8 hrs of in-service training on medication-related issues in each succeeding 12-month period. This requirement was not met based on evidence by:
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Administrator to have S1 through S5 staff complete the annual required medication training and submit proof of training to CCL by POC due date of 3/16/2023.
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Based on record review & interviews, facility failed to ensure that S1 – S5 had the required number of ongoing medication training hours per regulation which poses a potential safety risk.
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Type B
02/28/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met as evidenced by: Based on interviews & record review, facility didn't comply
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Facility to ensure that resident's needs are met according to care plan. Facility agrees to submit Department with a plan on how they will ensure that residents showers are occurring per agreed upon care plan will be met as needed by POC date of 2/28/2023 in order to clear this citation.
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w/section above resident care plan needs which poses a risk to health, safety, personal rights of resident in care. Department learned through interviews & record review that residents were not being showered per care plans of 2 x per week (see LIC 9099).
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**Civil Penalty are issued today in the amount of $250 for a repeated violation.
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: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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: DATE:
02/23/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Deborah Savoie, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Administrator does not accord dignity in their relationship with residents
Staff falsified medication log
Staff did not distribute medication to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator Deborah Savoie.
Administrator does not accord dignity in their relationship with residents – Complainant alleges that when residents try to have conversations with administrator regarding issues, administrator is not approachable, and is dismissive. LPA conducted six interviews with residents on 11/7/2023 and made observations on numerous facility field visits (11/7/23, 11/17/23, 12/2/23, 12/22/23). Interviews with residents revealed information that could be perceived as interpretation of Administrators personality or professional conduct, information obtained was not a violation of regulation. LPA did not obtain information to support the Administrator failed to treat residents in care with dignity or a specific incident that violated regulation of personal rights of residents in care. Therefore, this allegation is unsubstantiated.
Continue on LIC9099-C
……….
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
VISIT DATE: 02/23/2023
NARRATIVE
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Staff Falsified medication log & Staff did not distribute medication to resident - Complainant alleges R1 left the facility a day in the month of 10/2022 with individuals and returned later that evening to request evening medications from staff but was informed R1 had already received these medications as staff stated, they have been signed off in medication log. LPA reviewed 6 resident records and one record, R1’s was incomplete (CM for 87506 Resident Records – MARS not completed- repeat). LPA received conflicting information regarding date and time of outing. LPA obtained sign out sheet from facility of 10/2022 date that ends in the afternoon, although reporting party states return was in the evening. In August, 2022 the facility had a change of ownership, LPA conducted interviews with staff (S1) that revealed the old computer system was taken by the old company approximately a month after the change and the facility staff were having to use a paper logging system until a new computer system was brought in, which wasn’t until approximately October, 2022. Based on interview with Resident Care Coordinator (RCC) Samira Howeidy, LPA was informed shortly after the change of ownership the facility was not using electronic MARS and were using handwritten MARS. RCC informed LPA, facility was unable to provide written or locate MARS for the time period requested of 10/2022. Based on, LPA being unable to obtain medication documentation LPA was unable to prove staff falsified medication log or staff did not distribute medication to resident. Deficiencies for not filling out the MAR will be addressed on case management.

Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated .
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5