<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804058
Report Date: 05/20/2022
Date Signed: 05/20/2022 03:48:57 PM


Document Has Been Signed on 05/20/2022 03:48 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: 75DATE:
05/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator Nathan LaytonTIME COMPLETED:
03:48 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a subsequent pre-licensing inspection and met with Nathan Layton Administrator for Sunrise of Petaluma who is licensed at this property at this time. This is a change of ownership. LPA signed in and filled out electronic intake form and had temperature checked by electronic system. Fire clearance has been approved for capacity of 95 with 85 non-ambulatory residents and 10 bedridden, by the County Fire Department with a hospice waiver request for 12. There is a total of 75 residents, 35 dementia residents, and 7 residents under Hospice care.

LPA conducted first visit on 5/17/2022. During todays inspection LPA completed the pre-licensing inspection and COMP III with Administrator Nathan Layton.

Pre-Licensing is complete, and this facility has no apparent deficiencies. Facility is ready for licensure.



LPA will conduct record review and medication review during Post Licensing

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with process.

There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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 1