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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804058
Report Date: 04/29/2023
Date Signed: 04/29/2023 12:09:34 PM


Document Has Been Signed on 04/29/2023 12:09 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 83DATE:
04/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aaron Lawman, Resident Care DirectorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Resident Care Director, Aaron Lawman.

LPA is following up regarding nineteen residents who are currently residing in this facility following an evacuation from another licensed facility, Vista Terrace of Belmont. Per conversation with Resident Care Director (RSD), there are currently four caregivers and two Medication Technicians providing assistance to 46 assisted living residents and provided a staffing schedule that shows four caregivers and two Medication Technicians on the PM shift and two caregivers and one Medication Technician on the NOC shift. Per conversation, additional staff from the evacuated facility were expected at 12:00pm today but it was not clear how many were coming and how many would be on future shifts. LPA conducted a walk through of all rooms occupied by evacuated residents and did not note any immediate Health and Safety concerns. LPA confirmed with Resident Care Director that all resident care plans would be reviewed to ensure resident's needs are being met.

Per LPA observation all rooms had a bed and linens though some rooms are not furnished per regulation. Per conversation with the RSD, the facility is working on obtaining additional furniture. Additionally, LPA communicated to all residents that were unsure how to request assistance from caregivers that they may use the signal system inside their room to alert staff if they need help. Facility is ordering additional pendants for residents to use if they need caregiver assistance.

LPA has requested that a staffing schedule showing adequate staff for all shifts be completed and submitted to CCL no later than 12:00pm tomorrow, April 30, 2023.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2023
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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