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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804058
Report Date: 05/31/2023
Date Signed: 05/31/2023 03:45:53 PM


Document Has Been Signed on 05/31/2023 03:45 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:
05/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Deborah Savoie, Administrator TIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Pre-Licensing inspection and met with Administrator, Deborah Savoie.

During pre-licensing tour for CHOW 496804150 at approximately 11:00 AM (Fire inspection noted no delayed egress devices on north exterior gate from Memory Care to public pathway). LPA observed with Administrator delayed egress alarm off from Courtyard kitchenett to memory care patio. Then, LPA and Administrator observed gate on northeast side of memory care has a new operational egress device although, when tested, alarm went off and door opened, Administrator informed until the alarm is connected to a pager no one will be notified. (see LIC809-D). Facility will ensure sufficient staffing while Delayed Egress Door is not functioning to ensure residents safety.
Also during inspection observed by LPA and Administrator, Hot water temperature measured 124.1,125.6, 126.1, 127.9, 129.2, 129.5, 130.2,132, & 132.8 degrees F in 9 bathroom faucets (six of which are in Memory Care units) used by residents which falls out of regulation requirements of 105 to 120 degrees F. Blding Services Director Michael Sahati informed Administrator they were unable to lower boiler temperature and may need to wait until 6/2/2023 when company that manages boiler can come out to adjust. (see LIC809-D).

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) 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: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/31/2023 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2023
Section Cited
CCR
87705(j)

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87705(j) Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:todays facility inspection with Administrator.
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 Facility will ensure sufficient staffing while Delayed Egress Door is not functioning to ensure residents safety. (Per Administrator plan for security guard to be stationed in northeast memory care courtyard until alarm is audibol to
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 There was observed 1 auditory alarm not operational or turned off and there are residents with Dementia. New delayed egress device on memory care gate does not allert facility. This is an immediate risk to the health and safety of residents in care.
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facility will be submited by 6/1/2023 and meanwhile sufficient staff will be at facility.Admin to submit proof.

Facility to submit proof of repair on egress door shows functioning and all alarms are activated. by POC due date of 6/2/2023.
Type A
06/02/2023
Section Cited
CCR87303(e)(2)

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature...shall be maintained to automatically regulate the temperature of hot water used by residents...not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This has not been met as evidence by:
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Facility will submit proof maintance company has adjusted boiler by 6/2/2023 and will submit proof of log sheet for water temperature measurement that will be taken every month for six months.
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LPA measured hot water temperature for 9 random sampled restrooms in facility (6 in memory care) used by residents. Hot water measured124.1,125.6, 126.1, 127.9, 129.2, 129.5, 130.2,132, & 132.8 degrees F degrees F. Facility understands that hot water temperature has to measure 105 degrees F to 120 degrees F.
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Licensee will also send a statement stating that facility agrees to follow 87303(e)(2) regulation by 6/1/2023.
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: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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