Inspection Reports for
Windsong of Sonoma Senior Living

The complaint investigation was substantiated based on a preponderance of evidence that the facility did not provide a reappraisal or timely written notification to the resident's responsible party regarding increased care costs. Another allegation about communication with the responsible party was unsubstantiated.

The investigation substantiated that the facility failed to provide a resident with a timely reappraisal and written notification of increased care costs within two days. Another allegation regarding communication with the resident's responsible party was found unsubstantiated. The facility agreed to provide written notification within two business days as a plan of correction.

The complaint was substantiated based on observations, interviews, and records reviewed. The rodent problem was ongoing since January 2025 and had escalated, requiring multiple pest control visits without resolution.

The investigation substantiated the complaint that the facility had rodents, with observations of rodent feces, traps, and damage in the kitchen and dining areas posing an immediate health and safety risk.

The facility was found to be generally clean and compliant with safety and operational standards, including fire safety and medication administration. However, two direct care staff files lacked current first aid certification, posing a potential risk to residents.

The visit was complaint-related, following a self-reported incident of elopement by Resident 1, diagnosed with dementia and unable to leave the facility unassisted. The complaint was substantiated by the deficiency cited.

The facility failed to provide adequate supervision to a resident diagnosed with dementia, resulting in the resident eloping from the community. A deficiency was cited for absence of supervision, and a civil penalty of $500 was issued.

The complaint was substantiated. The allegation was that staff did not issue a refund to the resident's authorized representative. The resident passed away in early January 2025, and the refund was not processed timely. The refund was sent on the day of the investigation but was delayed beyond the 15-day regulatory requirement.

The investigation found that the licensee did not issue the refund within the required 15 days after the resident's belongings were removed, substantiating the complaint. The delay was due to processing lapses on the part of the business office and accounting.

The inspection found that resident R1, diagnosed with dementia, eloped from the facility on 6/11/2024, sustaining minor injuries. A citation and a civil penalty of $250 were issued for this repeat violation related to safety measures for persons with dementia.

The facility was generally clean and well-maintained with appropriate safety measures, but several deficiencies were found including staff not completing required annual trainings, unlocked medications and cleaning supplies in memory care areas, and hot water temperatures exceeding regulatory limits in some resident bathrooms.

The visit was complaint-related, following up on two self-reported incidents: an elopement on 10/20/2023 and an attempted suicide on 12/18/2023. The elopement incident resulted in a citation. Appeal of rights was given.

The inspection found that a resident with dementia eloped from the facility due to an unlocked garden latch, resulting in a citation. A second incident involved an attempted suicide requiring hospital transfer. Deficiencies related to safety measures for persons with dementia were cited but cleared at the visit after the facility provided elopement in-service training.

Complaint investigation was opened due to unsigned documents; the violation was substantiated as a technical violation for not following regulation 87507(c).

The License Program Analyst found that a resident did not have a signed Admissions Agreement, which is a violation of California Code of Regulations Title 22, Division 6, regulation 87507(c). The facility was given a technical violation but no citations were issued during the visit.

The facility provided proof of First Aid certifications completed on 2023-09-19, clearing that citation. Repairs were still in progress for water damage in the Garden Neighborhood dining area. The facility was cited for a medication error where a resident was given scheduled pain medication beyond the prescribed 3 days for an additional 8 days, posing an immediate health and safety risk.

The facility provided proof of First Aid certifications completed on 2023-09-19, clearing that citation. Repairs to the Garden Neighborhood dining area were still in progress. The facility was cited for a medication error where a resident was given scheduled pain medication beyond the prescribed 3 days without changing to PRN, posing an immediate health and safety risk.

The facility was generally clean and well maintained, but several deficiencies were noted including hot water temperature exceeding regulatory limits in memory care bathrooms, unlocked medication and wound care supplies accessible to residents, and incomplete staff certifications. Civil penalties were assessed for repeat violations and failure to timely report incidents.

The inspection found that the gate on the northeast side of memory care had a new operational egress device functioning properly. However, hot water temperatures in 3 of 6 resident bathroom faucets exceeded the regulatory maximum of 120 degrees Fahrenheit, measuring 120.6, 121.2, and 122.3 degrees Fahrenheit, constituting a deficiency.

The facility was toured and inspected, including resident apartments and common areas, with findings noting comfortable temperatures, unobstructed exits, and functioning fire safety systems. Some citations were noted related to hot water temperature exceeding regulatory limits and delayed egress door alarm not being connected to a pager.