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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804058
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:52:29 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
05/05/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230505122619
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: 74DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Deborah Savoie, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility lacks adequate staffing to meet resident's needs
Staff do not ensure residents have access to required furniture

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. Business Office Director Liz Alfaro signed, as Admin was in meeting.

Facility staff lacks adequate staffing to meet resident’s needs – complaint alleges due to additional residents joining facility from an evacuated facility there is not adequate staffing to meet residents care needs. On 4/29/23, 5/1/23, 5/4/23, & 5/9/23 Licensing Program Analysts (LPA’s) observed 46 residents in the assisted living section of the facility. Prior to residents being evacuated an informal meeting was held on March 24, 2023 to discuss areas of concern not limited to facility having adequate staffing. Residents were evacuated from sister facility on 4/28/2023. The staffing concern was also addressed in meetings held on 5/1/2023 & 5/11/2023 with the facility and management company to address evacuation and status.
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: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
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-20230505122619
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: 06/15/2023
NARRATIVE
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 5/1/23 Per conversation with Administrator and review of staffing schedule which indicates there are five caregivers and two Medication Technicians providing assistance to 47 assisted living residents. Staffing schedule obtained indicates four caregivers and two Medication Technicians on the PM shift and two caregivers and one Medication Technician on the NOC shift. On 5/9/2023 LPA was able to obtain additional documents from facility indicating there was 2 medication technicians from 6am until 10 pm and 1 medication technician on NOC shift (10pm -6am) covering the entire facility. There were 3-4 caregivers from 6am until 2pm and 3-4 caregivers from 2pm until 10pm and 2 caregivers on NOC shift. Departments discussion with staff on 5/10/2023 determined residents care needs include: 2 bedridden residents, 8 two person assists, and 7 one person assists. Based on staff schedule, interviews conducted with staff and residents and review of resident care needs the number of caregivers on shift is not sufficient to meet the resident care needs. The Department was provided a staffing schedule when evacuated residents arrived at the facility and then a subsequent staffing schedule that has not been adhered to based on LPA observations and review.

Staff do not ensure residents have access to required furniture- Complaint alleges new residents who arrived on 4/28/2023 do not have the appropriate furniture in their rooms besides, their beds. On 4/29/23 LPA observed with Resident Care Director (RCD) some resident rooms were not entirely furnished and directed RCD to ensure they were furnished per regulations. On 5/1/23, LPA was informed by Administrator, “Furniture has been ordered and should be at facility tomorrow, May 2, 2023”. On 5/4/23 LPA observation required furniture, per Title 22 regulations is not in rooms but was informed by Administrator “furniture has arrived at facility and will be set up in rooms tomorrow 5/5/2023”. On 5/9/23 LPA’s observed 3 of 5 rooms not having furniture in them as required and was informed by Resident Care Coordinator furniture has been ordered by maintenance and when it was delivered to the rooms the facility realized there was not enough furniture so they have ordered more.

The preponderance of evidence standard has been met; therefore, the above allegations, Facility lacks adequate staffing to meet resident’s needs & Staff do not ensure residents have access to required furniture are found to be Substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20230505122619
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: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2023
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 is not met based on evidence by:
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Facility has provided scheduling of staffing. Current resident’s in care has decreased by 13 (of the evacuated who have moved closer to their facility).

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Based on interviews and records review it was found that the facility did not ensure the number of staffing was sufficient based on resident level of care and increased census due to admissions from evacuated facility which poses an immediate health and safety risk for residents in care.
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 Proof that there is enough staffing to properly care for residents. Cleared at time of inspection
Type B
06/16/2023
Section Cited
CCR
87307(3)(B)
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87307 (3)(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers
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Based on LPA observations it was found that facility has equipped resident bedrooms with adequate furnishings. Deficiency cleared at time of inspection.

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Based on LPA observations and interviews with residents and staff facility did not provide required furnishings for resident’s bedrooms.
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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: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
05/05/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230505122619

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:
06/15/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Deborah Savoie, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility staff do not provide evening meals to residents in a timely manner
Facility staff are late to pick up residents from appointments
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.

Facility staff do not provide evening meals to residents in a timely manner – complaint alleges since additional residents have moved in, meals are coming out later than usual. Instead of being served between 5:15 pm to 5:30 pm residents were not able to eat until 6:00 PM. On 4/29/23, 5/1/23, 5/4/23, & 5/9/23 LPA conducted unannounced visits to the facility and observed meals being served in the dining room, bistro, and apartments at appropriate meal times. On 5/9/2023 LPA conducted interviews with 4 residents who informed, they have not had any problem getting their meals on time. Based on LPA observation and interviews conducted, facility meals are served at the posted hours. Residents sometimes arrive to the dining room early and staff provide beverages until the main meal is served.

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: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230505122619
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: 06/15/2023
NARRATIVE
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Facility staff are late to pick up residents from appointments – Complaint alleges staff who usually pick up a resident from medical treatments is now arriving late. Based on interview with R1, there are no complaints of being picked up or dropped off late for medical appointments regarding transportation. There was no evidence obtained to support the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations 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: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5