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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 09/21/2023
Date Signed: 09/21/2023 10:39:33 AM


Document Has Been Signed on 09/21/2023 10:39 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:SAVOIE, DEBORAHFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRIVETELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 72DATE:
09/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Business Office Director/ Designee, LIz AlfaroTIME COMPLETED:
10:45 AM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a case management of facility and met with Business Office Director Liz Alfaro regarding uncleared citation pertaining to First Aid certifications.

LPA is conducting this case management visit in order to clear deficiency previously cited during Post Licensing visit that occurred on 8/22/2023. POC due date was 8/31/2023 but on due date Administrator Savoie requested extension to 9/20/2023 which LPA granted. During today’s visit LPA was provided proof of First Aid certifications for staff (S1, S2, & S3) that was completed on 9/19/2023. LPA cleared citation at visit & provided Business Office Director (BOD) documentation.

During Post Licensing inspection on 8/22/2023 LPA observed Garden Neighborhood dining area blocked off (inaccessible to residents in care) due to water leak under the dishwasher causing damage to the floors and wall. Facility in process of making repairs. During today’s (9/21/2023) visit LPA observed same area still under repair, with progress made. LPA was informed by Building Services Director Russell Echevira, anticipated completion of repairs, including replacement of new kitchenette to be approximately 30 days. LPA was presented with receipts, work order documentation, and schedule.

While at facility conducting case management LPA was informed by BOD of incident report submitted to CCL last night of a medication error that occurred from 9/3/2023 to 9/10/2023 where Resident (R1) had been given pain reliever for 3 days, then was to be as needed, although facility continued with original order surpassing 3 days for 8 additional days of scheduled medication. PCP notified of incident, R1 back at baseline without any adverse side effects. Facility is being cited today for medication error. (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: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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 09/21/2023 10:39 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: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2023
Section Cited
CCR
87465(a)(5)

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87465(a)(5) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
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POC: Administrator shall provide a written statement on how future compliance will be met regarding change of daily medications to PRN to prevent incident again by POC due date of 9/22/2023.
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 This requirement was not met as evidenced by: Based on self-reported incident report and interview with RCC, pain med for R1 was to be PRN after 3 days, facility neglected to change for 8 additional days. This is an immediate health, safety and personal rights risk to residents in care.
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And Provide training to all staff who provide medications to residents in care on best practice on meds w end dates and med orders. Training log of name of training, who provided, dates, and signatures (w printed names next to signatures) submitted to CCL by 2nd POC due date of 10/2/2023.

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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: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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