WINDSONG OF SONOMA

Official classification

Type B

Official code

87309(c)

Regulation authority

CCR

What the official deficiency says

(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed bottle of Chardonnay, 12 pack of Coors light in glass bottles, two (2) bottles acetone unlocked and accessible to residents in MC unit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility to place locks and conduct in-service training for staff on how to properly store items that may pose a hazard to residents in care by plan of correction due date.

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA, RCD, and Admin record review, the licensee did not comply with the section cited above in that Med Tech staff (S1, S2, S3, S4, S5, S6, S7, and S8) did not have the required hours of medication training completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility to conduct medication training with all staff administering medication in requried number of hours by plan of correction due date.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Food items located in main kitchen and both ancillary Memory Care (MC) kitchens were not stored in a safe manner and open items were not covered or closed. Items found uncovered or unsealed or both include: tuna and egg salad, chicken tenders, frozen hamburger patties, frozen veggie patties, box of frozen peas, mini lemon pies, piece of cake, bread, buns, crisp rice dry cereal, and ice cream containers, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility to conduct in-service training with all kitchen staff on proper storage of food by plan of correction due date

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Ice cream found with frost bite and containers of strawberries had some berries with fuzzy black and blue substance present. Container of granulated sugar had active flies buzzing inside container as it was not properly sealed shut, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility immediately discarded items. Deficiency cleared.

Official classification

Type B

Official code

87555(b)(25)

Regulation authority

CCR

What the official deficiency says

(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed bleach and other toxins stored in main kitchen next to food preparation area, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility to conduct in-service training with kitchen staff on proper storage of toxins/cleaning products used in kitchen by plan of correction due date. Culinary director or designee will monitor proper storage of toxins cleaning solutions.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and RCD record review, the licensee did not comply with the section cited above in that resident (R5) did not have TB clearance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility to submit proof of tTB clearance for R5 by plan of correction due date.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and RCD record review, the licensee did not comply with the section cited above in that Residents (R1, R2, R3, and R4) do not have current physician reports on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2026 Plan of Correction Facility to submit current physician reports for R1, R2, R3, and R4 by plan of correction due date.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed unlocked kitchen cabinet under sink in both MC units to contain disinfectants and cleaning supplies. LPA and Admin observed three pair of scissors accessible unlocked and accessible to residents in MC unit, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility to place locks and conduct in-service training for staff on how to properly store items that may pose a danger to residents in care by plan of correction due date.

Official classification

Type B

Official code

1569.657(a)

Regulation authority

HSC

What the official deficiency says

(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure reappraisal was conducted and notification to responsible party was made within two days. This poses a potential risk to persons in care.

Official plan of correction

Licensee agrees to ensure written notification is provided to responsible parties within two business days. Violation cleared during visit as resident moved.

Deadline recorded: Mar 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of resident in care.

Official plan of correction

Previoues POC was Administrator submitted 5/6/2025 in-service training for entire staff re elopement procedures that will continue every month, & Initiated a 1:1 companion for R1’s safety. & indicated any memory care residnet leaves the unit will be handed off from person to person until brought back to memory care.(Admin & Regional Clinical Nurse). Administrator to submit thourough plan of how facility will meet regulation 87411 regarding memory care residents needs/safety, preventing elopement by POC due date 10/24/2025. ****A civil penalty is being assessed for $1,000.00

Deadline recorded: Oct 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above in that rodents, rodent feces and rodent traps were observed in the kitchen and dining areas which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

ED/Administrator agrees to submit thourough plan of how to eliminate the rodent infestation by POC due date of 10/24/2025.

Deadline recorded: Oct 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

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 Based on record review and interview with Administrator, the licensee did not comply with the section cited above in 2 out of 5 (S1 & S2) files reviewed of direct care providers did not have current 1st Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff (S1 & S2) first aid certification by POC due date of 6/6/2026.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of resident in care.

Official plan of correction

Administrator submitted 5/6/2025 in-service training for entire staff about elopement procedures that will continue every month, & Initiated a 1:1 companion for R1’s safety. POC cleared at time of visit ****A civil penalty is being assessed for $500.00

Deadline recorded: May 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.562(c)

Regulation authority

HSC

What the official deficiency says

1569.652 Termination of admission agreement upon death of resident; removal of resident's property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident's personal property has been removed from the facility shall be issued to the individual...responsible for the fees or..resident's estate, within 15 days after the personal property is removed. This requirement has not been met as evidenced by : Based on record review and statements received, licensee did not ensure the Health & Safety Code as required. This is a potential personal rights risk to residents.

Official plan of correction

Licensee to provide a written detailed plan on how the facility will ensure resident's refunds are issued accordingly and timely per H & SC. Facility to submit their plan to Community Care Licensing as plan of correction by POC due date 2/28/2025

Deadline recorded: Feb 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

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** Based on a review of facility incident reports and resident records it was found that resident (R1) had eloped from the facility without supervision. R1 is diagnosed with dementia and based upon Physicians Report, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.

Official plan of correction

Licensee/Administrator to ensure full staff training on elopements. Also to ensure plan for egress doors/gates along with pagers/phones are in working order. POC to submit training sheet signed & date by staff with self certification egress gates/doors are connecting with staff pagers/phones to CCL by 8/21/2024 to clear POC. ***Civil Penalty for $250. for repeat violation

Deadline recorded: Aug 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review & interview with Administrator, the licensee did not comply with the section cited above in 3 out of 3 direct care providers did not obatain required annual trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Administrator to submit proof of training to CCL for S1, S2, and S3 by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/28/2024.

Official classification

Type B

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA & Administrators observation while touring memory care, the facility did not comply with the section cited above by finding residents unlocked lidocane strips in unlocked bathroom cabinet (see pics), shampoos & conditioners with creams of multiple residents in unlocked bathroom cabinets (see pics), & finding cleaning supplies in memory care kitchenett's in unlocked cubbords (see pics) although all removed or lockes placed on cabinets by end of visit, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(2). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 6/28/2024.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

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 Based on record review and interview with Administrator, the licensee did not comply with the section cited above in 1 out of 3 (S1) direct care providers did not have current 1st Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction 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 6/28/2024.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e)Water supplies...shall be maintained... (2) Faucets used by residents...Hot water temperature controls shall be maintained...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 5 out of 11 residents bathroom faucets measured between 121.8 & 128.3 degrees F (all memory care residents) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Facility to submit proof of log sheet for water temperature measurement for the next 14 days to be submitted to CCL by 6/28/2024. Civil penalties for $250.are being assessed for a repeat violation of the same regulation in less then 12 months.

Official classification

Type B

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

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** 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.

Official plan of correction

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. POC cleared at visit.

Deadline recorded: Feb 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

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. 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.

Official plan of correction

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. 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.

Deadline recorded: Sep 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction 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.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction 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.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction 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.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 08/31/2023 Plan of Correction 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.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 08/31/2023 Plan of Correction 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.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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: LPA measured hot water temperature for 6 random sampled restroom faucets (1 in memory care) used by residents. Hot water measured 120.6, 121.2, & 122.3 degrees F in 3 of the faucets. Facility understands that hot water temperature has to measure 105 degrees F to 120 degrees F.

Official plan of correction

Facility will submit proof boiler has been adjusted by 6/16/2023 and will submit proof of log sheet for water temperature measurement that will be taken every month for six months. Administrator to ensure residents safety.

Deadline recorded: Jun 16, 2023. A deadline is not proof that correction was completed.