Inspection Reports for Windsong of Sonoma Senior Living

The visit was conducted as a Case Management - Incident Visit to follow up on a self-reported incident involving a resident who eloped from the facility on 10/10/2025.

The facility failed to provide adequate supervision to a resident with dementia, resulting in elopement. A repeat deficiency was cited for failure to meet personnel requirements, and a civil penalty of $1,000 was issued.

The visit was complaint-related, following a self-reported incident of elopement by a resident diagnosed with dementia. The deficiency was substantiated and a civil penalty was issued for repeat violation.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.

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 conducted as a Case Management - Incident Visit to follow up on a self-reported incident involving a resident elopement from the facility.

The facility failed to provide adequate supervision to a resident with dementia who eloped from the community, resulting in a cited deficiency and a civil penalty for absence of supervision.

The visit was complaint-related, following a self-reported incident of a resident with dementia eloping from the facility. The deficiency was substantiated and a civil penalty of $500 was issued for zero tolerance, absence of supervision.

The inspection was an unannounced complaint investigation triggered by an allegation that staff did not issue a refund to a resident's authorized representative.

The investigation found that the licensee did not issue the refund within the required 15 days after the removal of the resident's belongings, substantiating the complaint. The delay was due to lapses in processing and lack of staff knowledge of the refund regulation.

The complaint alleging that staff did not issue a refund to the resident's authorized representative was substantiated based on record review and interviews. The refund was not paid within the required 15 days after the resident's belongings were removed following the resident's death.

The inspection was an unannounced complaint investigation visit triggered by allegations including unlawful eviction of a resident and overcharging the resident.

The investigation found no evidence to support the allegations of unlawful eviction or overcharging. Interviews and document reviews confirmed the allegations were unfounded, and no deficiencies were cited.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.

The visit was an unannounced case management inspection to follow up on a self-reported incident where a resident eloped from the facility without staff knowledge.

The inspection found that resident R1, diagnosed with dementia, eloped from the facility on 6/11/2024, sustaining minor injuries. A citation and civil penalty were issued for failure to provide adequate supervision and safety measures.

The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing regulations and facility operations.

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 inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was retaliating against a resident.

The investigation found that the allegation of retaliation against the resident was false and without reasonable basis. The complaint was determined to be unfounded and was dismissed with no citations issued.

The complaint alleged that the facility was retaliating against a resident. The complainant later stated they did not want the complaint investigated and denied having a complaint. The investigation concluded the allegation was unfounded.

The visit was an unannounced case management inspection to follow up on two self-reported incident reports submitted to Community Care Licensing, including an elopement incident and an attempted suicide.

The inspection found that resident R1 eloped from the facility due to an unlocked garden latch, resulting in a citation. The facility also reported an attempted suicide by resident R2, who was sent to the emergency room and is being placed in a different facility post-discharge. A deficiency related to safety measures for persons with dementia was cited but cleared at the visit.

The visit followed up on two self-reported incidents: one involving resident R1 eloping from the facility without staff knowledge, and another involving an attempted suicide by resident R2. The citation was issued for the elopement incident.

An unannounced complaint investigation was conducted in response to allegations received on 10/04/2023 regarding staff not ensuring resident privacy, discriminating against a resident, and threatening a resident.

The investigation found no preponderance of evidence to substantiate the allegations. The complaints about staff not ensuring resident privacy, discrimination, and threats were all determined to be unsubstantiated based on interviews, record reviews, and observations.

The complaint investigation addressed allegations that staff were not ensuring resident privacy, discriminating against a resident, and threatening a resident. The investigation included interviews with staff and residents, record review, and observation. The allegations were found to be unsubstantiated.

The visit was an unannounced complaint investigation and case management visit to address unsigned documents at the facility.

The investigation found that one resident did not have a signed Admissions Agreement, which is a violation of California Code of Regulations 87507(c). The facility received a technical violation but no citations were issued during the visit.

Complaint investigation regarding unsigned documents; substantiation status not explicitly stated but a technical violation was issued.

The visit was an unannounced case management inspection to clear a previously cited deficiency related to First Aid certifications from a Post Licensing visit on 2023-08-22. The visit also addressed ongoing repairs and a medication error incident reported by the facility.

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 inspection was an unannounced Post-Licensing visit conducted to evaluate compliance with licensing requirements following initial licensing.

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 visit was a Case Management - Health Checks inspection conducted to deliver complaint findings and follow up on residents transferred from another licensed facility after an evacuation.

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.

An unannounced pre-licensing inspection was conducted due to a change of ownership and to evaluate the facility for licensing approval.

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.

The visit was conducted as a Change of Ownership application process for a Residential Care Facility for the Elderly, including a COMP II telephone interview to verify identification and understanding of California Code Title 22 Regulations.

The applicant and administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restricted health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. No deficiencies or violations were noted in the report.