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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804058
Report Date: 12/02/2022
Date Signed: 12/02/2022 12:52:31 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
09/02/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20220902140830
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: 69DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Deborah Savoie - Administrator TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Residents are not showered timely due to a lack of staff
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.
Residents are not showered timely due to a lack of staff – Complainant alleges that residents are not showered in a timely manner because facility did not have staff or a schedule. LPA obtained text documentation in which staff (S1) confirmed with resident (R1)’s responsible party that R1 had not received a shower in 15 days (8/10/22 – 8/25/22). In addition, LPA conducted interviews on 10/20/22, in which previous resident care director (S2) corroborated residents were not getting showers because facility was short of staff. Other interviews conducted by LPA with responsible party of R2 confirmed there were 10-day increments in which residents did not receive showers although their care plan states residents are to receive 2 showers per week. The preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.
Continued on 9099-C
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: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
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-20220902140830
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: 12/02/2022
NARRATIVE
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The preponderance of evidence standard has been met; therefore, the above allegation is 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: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220902140830
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: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2022
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 has not been met as evidenced by: Based on interviews & record review, facility didn't comply
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Facility to ensure that resident's needs are met according to care plan. Facility agrees to submit Department with a plan on how they will ensure that residents showers are occurring per agreed upon care plan will be met as needed by POC date of 12/09/2022 in order to clear this citation.
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 w/section above resident care plan needs which poses a risk to health, safety, personal rights of resident in care. Department learned through interviews & record review that residents were not being showered per care plans of 2 x per week (see LIC 9099).
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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: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
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
09/02/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20220902140830

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:
12/02/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff is not providing supervision due to insufficient staffing
Residents are left in dirty clothes
Residents are being locked out of their rooms
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.
Staff is not providing supervision due to insufficient staffing – Complainant alleges there is an absence of supervision due to insufficient staff. LPA obtained the staff schedule for September/2022 and based on records reviewed, facility has 1 MedTech for both memory care units, 3 AM staff, 3 PM staff, and 1 NOC shift staff scheduled in each unit. In September/2022 there were 17 residents in memory care unit, Garden Generation. During the course of the investigation LPA conducted interviews which revealed at times a staff may call out sick and agency were not always reliable to show up, LPA was informed if needed the program coordinator and managers will step in to ensure sufficient staffing. Record review of incident reports for the month of September/2022 did not indicate incidents were due to staff not providing supervision. Although the investigation revealed facility is experiencing staffing challenges the investigation did not reveal a specific incident that proves residents had a lack of supervision. LPA was unable to prove staff is not providing supervision due to insufficient staffing Therefore, this allegation is unsubstantiated.
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: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
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-20220902140830
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: 12/02/2022
NARRATIVE
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Residents are left in dirty clothes – Complainant alleges facility is not changing residents closes from one day to the next. On 9/09/22, 10/20/22 & 11/07/2022 LPA conducted unannounced visits to the facility and observed residents in both memory care units and in the assisted living area to be dressed in clean clothing with no odor. LPA also conducted interviews with current and former staff and residents and was unable to obtain information to support residents are left in dirty clothes. Therefore, this allegation is unsubstantiated.
Residents are being locked out of their rooms – Reporting party stated residents responsible party was informed, to prevent a wandering resident from entering others rooms the facility could lock R1, R3, and R4’s rooms to ensure the wanderer did not enter. RP did not indicate there was an instance of a resident being locked out their room. Interviews with staff, residents, and related parties, as well as LPA’s observations on three unannounced visits did not reveal evidence of residents being locked out of their rooms. In fact interview with R5 stated “residents all have our own keys to our apartments that are on a bracelet to take with us and I do lock my door when I leave” and staff informed LPA as this is a memory care unit staff also have keys and can assist residents into their room if they are not able to utilize their key. Therefore, this allegation is unsubstantiated.

Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation 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: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5