496804150-6-4-2024-21-AS-BMOS-D6DNEU-20240619102431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804150
Report Date: 06/03/2024
Date Signed: 06/04/2024 11:53:42 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20240528162916

FACILITY NAME:	WINDSONG OF SONOMA		FACILITY NUMBER:	496804150
ADMINISTRATOR:	JOHN BELTZ		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DRIVE		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS: 77	DATE:	06/03/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Sammy Howeidy/Director of Memory Care		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility is retaliating against resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrives unannounced for the purpose of investigating the above captioned complaint allegation. LPA has taken a statement from the Complainant on 5/31/2024 and from facility staff this date. LPA has reviewed pertinent documents. Facility staff deny retailiating against the Complainant and indicate the Complainant is the subject of an eviction proceedure which has been issued in accordance with current law and Title Twenty-Two regulations. On May 31, 2021 Complainant indicated to CCL staff that Complainant did not want the complaint to be investigated. When asked if Complainant did, or did not, have a complaint with the facility, complainant responded, "No." Based upon the statements made and documents reviwed, we have determined that the allegation that the facility is retaliating against resident is false and without a reasonable basis. Therefore, the complaint is UNFOUNDED. The complaint is DISMISSED.
Report left. No citations issued today.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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