496804150-8-23-2023-21-AS-SHAN-CUYLJX-20230823084840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 08/22/2023
Date Signed: 08/23/2023 08:48:53 AM

Document Has Been Signed on 08/23/2023 08:48 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 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: 74	DATE:	08/22/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Deborah Savoie, Administrator & Elizabeth Alfaro, Buisness Office Manager		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Post-Licensing Inspection and was welcomed by Business Office Mgr. Elizabeth Alfaro, and met with Administrator Deborah Savoie, who arrived later to facility. Facility is 2 stories and contains both assisted living and memory care with a total of 35 Assisted Living and 39 dementia residents in 2 memory care units. There are 9 residents currently on Hospice. Facility tour/inspection began at 8:35 AM: LPA toured the facility on 8/22/2023 at approximately 8:35 AM with Business Office Manager (BOM) Lizabeth Alfaro; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 10/10/2022. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 7/15/2023. Every resident apartment has an individual smoke detector in addition to hard wired. LPA observed 3 out of 3 Carbon monoxide detectors that were found to be operational. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 113 degrees F and 121.8 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 6 of 10 resident’s bathroom faucets, all 6 in memory care (see LIC809-D). The facility as special care plan of operation and programming for residents with dementia. Facility serves residents without dementia as well. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Menus are available and provided during meals. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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: 08/22/2023

NARRATIVE

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LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents posted on the wall. Toxins are stored in a locked housekeeping room; although while touring facility at 9:24am LPA & BOM observed unattended unlocked Insulin cart with medication accessible to residents (see LIC809-D). There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with towels and hand soap dispensers when a private room; although at 8:40am LPA & BOM observed in a memory care bathroom an unlocked cabinet with wound cleaner, see pic (see LIC809-D).

Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. While touring facility LPA observed Garden Neighborhood dining area blocked off and was informed by Building Services Director Russell Echevira, a leak under the dishwasher has been causing water damage for some time and the floors and a wall in the room have been removed for sterilization. The incident had not been reported as required to the department (see LIC 809-D).

File Review began at 11:30 AM:
A sample review of five residents & five staff records as well as four resident’s medications was conducted. LPA learned that 5 out of 5 residents have an updated reappraisal/needs & care plan as well as medical assessments. As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements; although records revealed only 3 of the 5 staff (S1, S2, S3) reviewed had required proof of CPR & 1^st Aid certification (see LIC 809-D). In addition, Deborah Savoie, Administrator Certificate # 6007136740 recertification is pending.

Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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: 08/22/2023

NARRATIVE

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Medication Audit began at 1:20 PM:
Medications were centrally stored in locked medication carts and in the facility medication room at the facility. LPA observed medications of 4 out of 4 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 4 out of 4 residents were found to have all medications entered for residents. Facility uses bubble pack and pharmacy CSMR for all residents at the facility.

LPA reviewed Licensing Information System (LIS) with Executive Director who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted monthly and in different shifts with the last one being conducted on 7/13/2023.

At today’s visit LPA is also citing facility for not following reporting requirements. The department received an incident report from facility on 8/16/2023 regarding resident (R1) who on 8/6/2023 was taken to the hospital for fracture of ribs (see LIC 809-D).

Civil Penalties are being assessed in the amount of $250.00 for a repeat violation within the last 12 months.

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.

LPA Hansen is requesting Administrator to update the following documents and to submit to CCL by 9/8/2023:

LIC 308 Designated
LIC 500 Personnel Summary (already received)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s(already received)
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2023 08:48 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 6 out of 10 residents bathroom faucets measured between 120.7 & 121.8 degrees F (all memory care residents) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Facility will submit proof boiler has been adjusted by 8/23/2023 and will submit proof of log sheet for water temperature measurement for the next 7 days to be submitted to CCL by 8/31/2023. Civil Penalties have been assessed for repeat violation in the last 12 months for $250. 00.

Type A

Section Cited

CCR

87705(f)(2)

87705(f)(2)Care of Persons w/Dementia -The following shall be stored inaccessible to residents with dementia. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 1 unlocked bathroom cabinet, in memory care, containing wound cleaner was observed by LPA & BOM during inspection, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that toxins, medications & other items that constitute danger to residents are locked & inaccessible at all time. Licensee agrees to lock maintain toxins locked at all times. Licensee to submit Department w/LIC 9098 self certification that all items that constitute danger to residents are locked by POC date of 8/23/2023. In addition, proof of staff training on Regulation #87705 by 8/31/2023 in order to clear this citation.

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: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2023 08:48 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2)Incidental Medical and dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... ***This requirement not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation by LPA & BOM the facility Insuline medication cart was unlocked and unattended containing suringes and insuline which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Administration will send letter acknowledging understanding of regulations to CCL by POC 8/23/2023 and provide refresher training to staff regarding the requirements of 87465 and will provide proof of training log with dates, signatures, and name of training with trainer to CCL by POC date 8/31/2023 in order to clear the deficiency.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2023 08:48 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)

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)... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on document review and interview with Administrator showing R1’s incident report to hospital on 8/6/2023 was not reported timely. & Based on observation and interview with Director of Building services that facility has major water damage in dining room of memory care unity that was not reported, this is a potential risk to resident in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	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, 8/31/2023 and submit a copy of signed and dated log.

Type B

Section Cited

CCR

87411(c)(1)

87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and record review, 3 out of five staff lacked required first aid certification, the licensee did not comply with the section cited above in three out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 8/31/2023.

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: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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