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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 02/01/2024
Date Signed: 02/01/2024 09:41:57 AM


Document Has Been Signed on 02/01/2024 09:41 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:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRIVETELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 77DATE:
02/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:MARY MCCLURE, Administrator TIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conducted an unannounced case management and met with Administrator, Mary McClure. The purpose of this case management inspection is to follow up on two self-reported incident reports submitted to Community Care Licensing (CCL).

CCL received the first self-reported incident report form on 10/25/2023 reporting on 10/20/2023 at approximately 1:35 pm resident (R1) had eloped from community. Facility staff conducted search and located R1 at a local park at approximately 3:10 pm. Report states garden latch was not locked by gardeners who obtained key from staff to conduct work, when elopement occurred. No visible signs of injury noted by resident care director (RCD) and R1 denied any pain. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave unassisted. Interview with RCD informed R1 exit seeks. LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 10/20/2023.

LPA also followed up on a second incident submitted to CCL on 12/19/2023 of an attempted suicide on 12/18/2023 where R2 was sent out to emergency room. Resident is being placed in different placement from discharge from hospital.

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: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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 02/01/2024 09:41 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: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2024
Section Cited
CCR
87705(b)(2)

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87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by**
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Facility provided Elopement in-service training conducted, for regulation 87705 Care of Persons with Dementia with staff.

LPA Obtained copy of trainings w signatures and dates.
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Based on record review it was found that resident (R1) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.
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POC cleared at visit.

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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: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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