496804150-5-31-2023-21-AS-SHAN-CSCUMZ-20230531154309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 05/31/2023
Date Signed: 05/31/2023 03:43:17 PM

Document Has Been Signed on 05/31/2023 03:43 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 SONOMA		FACILITY NUMBER:	496804150
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: 82	DATE:	05/31/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Deborah Savoie, Administrator		TIME COMPLETED:	03:55 PM

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License Program Analyst (LPA) Hansen arrived at 10:15 AM to conduct an unannounced pre-licensing inspection and met with Administrator, Deborah Savoie. This is a change of ownership. Fire clearance has been approved for capacity of 95 with 80 non-ambulatory residents and 15 bedridden, by the County Fire Department. There is a total of 82 residents, 39 dementia residents, 11 bedridden, and 7 residents under Hospice care. Currently there are 16 evacuated residents from Vista Terrace of Belmont in 13 Assisted Living Apartments.

Facility tour/inspection began at 10:30 AM:

Beginning at approximately 10:30 AM, LPA toured the community with Deborah Savoie, Administrator and was joined by Building Services Director, Michael Sahati. The tour of the facility included resident apartments, activity rooms, Library, Salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstructions. The assisted living residents also have an outdoor patio courtyard. Egress doors from the memory units (Generation Garden & Generation Courtyard) have audible alarms when doors are opened without access codes. The front door and main exits from the assisted living area also have audible Wanderguard system. Fire inspection noted no delayed egress devices on north exterior gate from Memory Care to public pathway. At 11:00 AM LPA and Administrator observed gate has a new operational egress device although, when tested, alarm went off and door opened, Administrator informed until the alarm is connected to a pager no one will be notified. Facility will ensure sufficient staffing while Delayed Egress Door is not functioning to ensure residents safety (citation on existing license). Hot water temperature measured 124.1,125.6, 126.1, 127.9, 129.2, 129.5, 130.2,132, & 132.8 degrees F in 9 bathroom faucets used by residents which falls out of regulation requirements of 105 to 120 degrees F.(citation on existing license). Bathrooms contained necessary grab bars and shower contained non-slip floor/mats. LPA observed at least a minimum of a 2-day supply of perishable and 7-day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchen were inspected and well maintained. Menus and activity schedules are posted. Facility has a media room and multiple indoor and outdoor sitting areas and a private dining area for residents and visiting families for special occasions.

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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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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: 496804150
	VISIT DATE: 05/31/2023

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Emergency disaster drills are conducted quarterly and during different shifts with the last Disaster Drill conducted on 4/27/2023. Fire extinguishers were current and charged as of 10/10/2022. Fire safety system including smoke detectors and carbon monoxide detectors are checked quarterly. Smoke detectors are hardwired on the first & second floors and in all common rooms and hallways. Carbon monoxide and smoke detectors were observed to be working at the time of the visit.

LPA completed COMP III with Administrator Deborah Savoie.

See Existing License496804058 for citations issued during today’s Pre-Licensing

LPA will conduct record review and medication review during Post Licensing

LPA will notify Application Unity of today’s inspection

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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