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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 08/20/2024
Date Signed: 08/20/2024 09:25:37 AM


Document Has Been Signed on 08/20/2024 09:25 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:
496804150
ADMINISTRATOR:JOHN BELTZFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRIVETELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 80DATE:
08/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Business Office Director, Elizabeth AlfaroTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility to conduct a case management and met with Elizabeth Alfaro, Business Office Director (BOD) as Administrator, John Beltz was not available. The purpose of this case management inspection is to follow up on a self-reported incident report submitted to Community Care Licensing (CCL).

On 6/14/2024 CCL received an incident report form reporting on 6/11/2024 at approximately 4:45pm resident (R1) had eloped from community. Facility staff conducted search at 4:50pm, after not locating R1 in facility staff left in car and at the same time as Law Enforcement located R1 two intersections away laying on the lawn at approximately 5:20pm. Report indicates R1 sustained 2 skin tears on left hand with bruise on palm. 911 contacted after returning to community. EMT’s evaluated & cleared for resident to remain at facility. Staff informed, R1 left through back egress gate of facility memory care unit. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave facility unassisted. Interview with staff informed R1 exit seeks. LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 6/11/2024.

*******Total Civil Penalties issued today in the amount of $250.00

A $250.00 civil penalty is being issued for 2nd citation in less then 12 months for the same violation 87705(b)(2). Previous citation 2/1/2024.

Appeal Rights Given

The following deficiencies were observed (see LIC 9099D) 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: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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 08/20/2024 09:25 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: 496804150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
87705(b)(2)

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87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on a review of facility incident reports and resident records it was found that resident (R1) had eloped from the facility
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Licensee/Administrator to ensure full staff training on elopements. Also to ensure plan for egress doors/gates along with pagers/phones are in working order.
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without supervision. R1 is diagnosed with dementia and based upon Physicians Report, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.
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POC to submit training sheet signed & date by staff with self certification egress gates/doors are connecting with staff pagers/phones to CCL by 8/21/2024 to clear POC.

***Civil Penalty for $250. for repeat violation

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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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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