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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:59:19 PM


Document Has Been Signed on 10/05/2023 03:59 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: 75DATE:
10/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Business Office Director/ Designee, LIz Alfaro & Sammy Howeidy, Memory Care DirectorTIME COMPLETED:
04:15 PM
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License Program Analyst (LPA) Hansen arrived unannounced to open a complaint at facility and conduct a case management of facility and met with Business Office Director Liz Alfaro and Sammy Howeidy, Memory Care Director regarding unsigned documents.

During complaint investigation LPA was informed resident (R1) did not have a signed Admissions Agreement. Which is a violation of regulation 87507(c). Facility will obtain a signed admissions agreement from all residents.

LPA is giving facility a technical violation for not following California Code of Regulations Title 22, of Division 6, of California Regulations 87507(c).

No citations given during today's visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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