496804058-12-22-2022-21-AS-BMOS-CMJPUE-20221228103725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804058
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:47:02 AM

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-20220902091320

FACILITY NAME:	WINDSONG OF SONOMA		FACILITY NUMBER:	496804058
ADMINISTRATOR:	SAVOIE, DEBORAH		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DRIVE		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS: 66	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Deborah Savoie - Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Reporting requirements

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.
Reporting requirements not met – On 8-1-2022 facility came under new ownership. On 9/7/2022 LPA conducted an unannounced visit to open this complaint and was informed by facility incident reports had not been provided to CCL. On 9/9/2022 LPA received 12 incident reports that occurred between 8/8/2022 and 8/26/2022. Regulation 87211 for reporting requirements states, each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. On 9/29/2022 LPA contacted Administrator and discussed reporting requirements again. Administrator informed LPA they would be handling that duty in the meantime. On 9/30/2022 CCL received incident report from facility regarding a resident that had an unwitnessed fall and was transported to hospital on 9/12/2022. As well the facility did not notify CCL of medication refusals for resident.
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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 21-AS-20220902091320

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: 12/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/29/2022 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)...	1 2 3 4 5 6 7	Facility Administrator agrees to have staff who are responsible for reporting incidents complete an in-service training regarding regulation 87211 no later than POC due date, 12/29/2022 and submit a copy of signed and dated log.
	8 9 10 11 12 13 14	This requirement has not been met based on document review and interview showing that at least fourteen incident reports have not been submitted timely. This is a potential risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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-20220902091320

FACILITY NAME:	WINDSONG OF SONOMA		FACILITY NUMBER:	496804058
ADMINISTRATOR:	SAVOIE, DEBORAH		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DRIVE		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS: 66	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Deborah Savoie - Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident sustained multiple falls resulting in injury
Staff did not ensure resident's medication was administered per doctors orders
Staff did not seek timely medical attention for resident
Staff did not properly address resident's multiple falls at facility

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.
Resident sustained multiple falls resulting in injury, Staff did not seek timely medical attention for resident, Staff did not properly address resident’s multiple falls at facility – Complaint alleges R1 sustained multiple “skin tears” (legs, arms and hands) that they believe were from falls between 8/9/2022 and 8/12/2022 adding that there were no staff present and resident was left unsupervised. Record review indicates R1 had 2 falls with no injury on 8/15/2022 and 8/18/2022. No falls noted between 8/9/2022 and 8/12/2022. Record review indicates that resident receives assistance with transferring but not that they required one to one supervision. Per narrative charting R1 did not sustain injury on 8/15/2022 or 8/18/2022 that required hospitalization. Per facility notes responsibility party and hospice were notified.
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220902091320

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: 12/22/2022

NARRATIVE

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Continuation of LIC9099-A
Review of residents care plan indicates that facility knew that resident was a fall risk and created interventions to assist resident including but not limited to “observe and report any changes in gait and or /balance, provide a safe environment clutter free…, provide first aid if indicated and obtain assistance from EMS if appropriate”. Reporting party noted a fall on 5/14/2021 which occurred under the former facility at this location and per file review resident was sent to hospital. During the course of this investigation LPA conducted interviews with individuals, staff and residents, record reviews and made observations. The department was not provide sufficient evidence to substantiate these allegations. 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.

Staff did not ensure resident’s medication was administered per doctor’s orders – Complaint alleges that R1 is not administering their own medication, in the form of refusing when given by staff. During the course of this investigation LPA conducted record reviews and interviews, per resident’s care plan staff will assist with self-administration of medications. Record review of communication from facility to the doctor, notes “resident often refuses medication or spits it out.” Additional record review notes medication refusal by resident on 8/8/2022. Interviews with staff (S1) & S2 further supported the resident periodically refused medications. Per file review LPA observed that the medication administration record (MAR) was not always completed and did not note reason for medications not being administered, including but not limited to resident refusals. Deficiencies for not filling out the MAR will be addressed on case management.
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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 4 of 4