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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804058
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:43:44 AM


Document Has Been Signed on 12/22/2022 11:43 AM - 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: 66DATE:
12/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Deborah Savoie , AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced and is conducting a Case Management visit because of deficiencies that were observed during a Complaint Investigation.

Licensing Program Analyst (LPA) Hansen observed facility uses Medication Administration Records (MARS) to document medication records. Facility uses a MAR which documents each medication dose that a resident is given by staff initializing the field when medication is given. Per file review, three residents were noted to have fields missing that may indicate a missed medication. LPA conducted interviews with S1 and S3 to confirm use of MARS and procedure if a resident refuses medication. Based on investigation the facility failed to always complete all MARS refusals and did not note reason for medications not being administered, including but not limited to resident refusals. Deficiencies cited Resident Records 87506(a) See LIC809-D.

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: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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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Document Has Been Signed on 12/22/2022 11:43 AM - 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: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited

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87506 Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Facility Administrator to have medical staff trained on filling out MARs and submit signed and dated ledger of all staff who attended training with the name of the training by POC due date of 1/6/2023.
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This requirement is not met as evidenced by: Based on file review, facility did not follow their plan of operation for medication administration documentation approved by department, in at least 3 resident’s MARS not being completed. This is a potential Health & Safety risk to residents in care.
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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: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
LIC809 (FAS) - (06/04)
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