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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804058
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:46:08 PM


Document Has Been Signed on 05/16/2023 03:46 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
CCLD Regional Office, 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: 82DATE:
05/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Deborah Savoie, Administrator TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator, Deborah Savoie.

LPA is following up regarding twenty residents who are currently residing in this facility following an evacuation from another licensed facility, Vista Terrace of Belmont. Per conversation with Administrator and review of staffing schedule, there are currently four caregivers and two Medication Technicians providing assistance to 45 assisted living residents. Staffing schedule shows four caregivers and two Medication Technicians on the PM shift and two caregivers and one Medication Technician on the NOC shift. LPA conducted a walk through and did not note any immediate Health and Safety concerns. Per Administrator, evacuated facility, Vista Terrace of Belmont will now be staying an additional three to six months at facility. Ordered furniture has been received and remaining items will be assembled and distributed tomorrow, May 17, 2023, per Administrator.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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