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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 06/15/2023
Date Signed: 06/15/2023 03:03:14 PM


Document Has Been Signed on 06/15/2023 03:03 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 SONOMAFACILITY NUMBER:
496804150
ADMINISTRATOR:SAVOIE, DEBORAHFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRIVETELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 74DATE:
06/15/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Deborah Savoie, AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conducted a Health & Safety Case Management inspection. LPA met with Administrator, Deborah Savoie.

LPA is following up regarding twenty additional residents who were residing in this facility following an evacuation from another licensed facility, Vista Terrace of Belmont. Per conversation with Administrator there are now only 7 residents from Vista Terrace with one more leaving at the end of the weak, some of these residents moved closer to original facility. There is currently 35 residents in the assisted living section, there are currently 4 caregivers and 1 Medication Technician.

At 12:37 pm, LPA observed gate on northeast side of memory care with new operational egress device is now functioning. LPA also checked hot water temperatures of 6 resident bathroom faucets at 1:05 pm and found faucets used by residents measured at 120.6, 121.2, & 122.3 degrees F in 3 of the 6 residents bathroom faucets (one of which is in Memory Care) falls out of regulation requirements of 105 to 120 degrees F. (see LIC809-D).

Appeal of Rights Given.

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: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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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Document Has Been Signed on 06/15/2023 03:03 PM - 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: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2023
Section Cited
CCR
87303(e)(2)

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature...shall be maintained to automatically regulate the temperature of hot water used by residents...not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This has not been met as evidence by:
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Facility will submit proof boiler has been adjusted by 6/16/2023 and will submit proof of log sheet for water temperature measurement that will be taken every month for six months. Administrator to ensure residents safety.
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LPA measured hot water temperature for 6 random sampled restroom faucets (1 in memory care) used by residents. Hot water measured 120.6, 121.2, & 122.3 degrees F in 3 of the faucets. Facility understands that hot water temperature has to measure 105 degrees F to 120 degrees F.
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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: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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