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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 06/11/2026
Date Signed: 06/11/2026 01:05:38 PM

Document Has Been Signed on 06/11/2026 01:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WINDSONG OF SONOMAFACILITY NUMBER:
496804150
ADMINISTRATOR/
DIRECTOR:		LAUREN COTTMANFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRIVETELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 95CENSUS: 80DATE:
06/11/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lauren Cottman, AdminTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo returned unannounced to complete the required Annual inspection and was greeted by concierge. LPA met with Administrator Lauren Cottman.

On 6/9/26 LPA arrived at facility to conduct annual inspection. Today, LPA returned to complete inspection.

At approximately 10:30am LPA, Admin, and MedTech began spot check of medication. Facility uses an electronic MAR and medication management system. Signed doctors' orders were on file. Facility utilizes e-MAR for PRNs. LPA advised to MedTech to ensure both reason for administering and outcome of administration are recorded and to provide as much detail as applicable. LPA advised that doctors' ordered must be followed per written instructions.

LPA, Admin, and MedTech discussed medication documentation management and possibly incorporating an organizational system that houses all the current signed doctors' orders and discontinuation notices in one location for each resident. Admin provided LPA recent pharmacy audit documentation conducted on 2/13/26. All audit criteria shows as met or not applicable. No deficiencies cited.

LPA issued citation for deficiencies identified on 6/9/26, except one. LPA did not issue citation for deficiency of Health and Safety Code (HSC)1569.696 as Admin provided LPA documentation showing all subject matters were covered by vendor training. Therefore, facility found to be in compliance with HSC1569.69. No deficiencies identified at today's continuation visit.

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150
VISIT DATE: 06/11/2026
NARRATIVE
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Continued from 809...

Additionally, Resident Care Director (RCD) provided LPA with proof of request for medical assessment for R5. So, LPA removed R5 from list of residents for deficiency of regulation 87463(h).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 01:05 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/11/2026 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed bottle of Chardonnay, 12 pack of Coors light in glass bottles, two (2) bottles acetone unlocked and accessible to residents in MC unit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Facility to place locks and conduct in-service training for staff on how to properly store items that may pose a hazard to residents in care by plan of correction due date.
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA, RCD, and Admin record review, the licensee did not comply with the section cited above in that Med Tech staff (S1, S2, S3, S4, S5, S6, S7, and S8) did not have the required hours of medication training completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Facility to conduct medication training with all staff administering medication in requried number of hours by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 01:05 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/11/2026 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Food items located in main kitchen and both ancillary Memory Care (MC) kitchens were not stored in a safe manner and open items were not covered or closed. Items found uncovered or unsealed or both include: tuna and egg salad, chicken tenders, frozen hamburger patties, frozen veggie patties, box of frozen peas, mini lemon pies, piece of cake, bread, buns, crisp rice dry cereal, and ice cream containers, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Facility to conduct in-service training with all kitchen staff on proper storage of food by plan of correction due date
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Ice cream found with frost bite and containers of strawberries had some berries with fuzzy black and blue substance present. Container of granulated sugar had active flies buzzing inside container as it was not properly sealed shut, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Facility immediately discarded items. Deficiency cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 01:05 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/11/2026 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed bleach and other toxins stored in main kitchen next to food preparation area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Facility to conduct in-service training with kitchen staff on proper storage of toxins/cleaning products used in kitchen by plan of correction due date. Culinary director or designee will monitor proper storage of toxins cleaning solutions.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and RCD record review, the licensee did not comply with the section cited above in that resident (R5) did not have TB clearance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Facility to submit proof of tTB clearance for R5 by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 01:05 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/11/2026 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and RCD record review, the licensee did not comply with the section cited above in that Residents (R1, R2, R3, and R4) do not have current physician reports on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2026
Plan of Correction
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2
3
4
Facility to submit current physician reports for R1, R2, R3, and R4 by plan of correction due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 01:05 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/11/2026 at 12:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed unlocked kitchen cabinet under sink in both MC units to contain disinfectants and cleaning supplies. LPA and Admin observed three pair of scissors accessible unlocked and accessible to residents in MC unit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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2
3
4
Facility to place locks and conduct in-service training for staff on how to properly store items that may pose a danger to residents in care by plan of correction due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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