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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804075
Report Date: 01/09/2025
Date Signed: 01/09/2025 10:55:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
11/12/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241112160946
FACILITY NAME:WINDROSE CARE HOMEFACILITY NUMBER:
496804075
ADMINISTRATOR:SOLOMON, BANAFACILITY TYPE:
740
ADDRESS:1759 WINDROSE LANETELEPHONE:
(707) 852-5025
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 6DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Bana Solomon-AdministratorTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Staff does not allow resident to watch television
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/9/2025 at approximately 9:40am, and met with Administrator Bana Solomon.

LPA reviewed resident files, and staff files. LPA conducted interviews with staff, S1 S2 S3 S4, and other related parties. Reporting party alleges that “staff does not allow resident to watch television”.

The investigation revealed that a staff/caregiver had put a resident’s television on a timer to shut off at a specific time in the evening. In summary, staff, S4, stated the resident watches television late into the night, and they are always tired the next day; Staff/S4 stated they weren’t told to do this by any other staff person, and they thought it was okay to do it.

Per interviews, resident's television turned off by timer without resident's permission, resident had no knowledge the television having been put on a timer in the evening.LPA discussed regulations regarding resident rights/personal rights with staff interviewed. Per i nvestigation, there is sufficient information obtained to support a violation had occurred.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20241112160946
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDROSE CARE HOME
FACILITY NUMBER: 496804075
VISIT DATE: 01/09/2025
NARRATIVE
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Per LPA’s investigation, including interviews with staff, S4, and interviews with other related parties, the allegation “staff does not allow resident to watch television” is Substantiated. This deficiency will be cited, 87468.2(a)(6) Additional Personal Rights of Residents in Privately Operated Facilities-In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To make choices concerning their daily lives in the facility, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with the Administrator Bana Solomon.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20241112160946
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINDROSE CARE HOME
FACILITY NUMBER: 496804075
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
87468.2(a)(6)
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87468.2(a)(6) Additional Personal Rights of Residents in Privately Operated Facilities-In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by:
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Licensee to ensure all staff obtain personal rights/residents rights training. Submit proof of training by 1/24/25, include trainers name, date/time spent, topics covered. POC due by 1/24/25.
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LPA's investigation, review of records, including interviews with staff and other parties; The investigation revealed that a staff/caregiver had put a resident’s television on a timer to shut off at a specific time in the evening. In summary, staff, S4, stated the resident watches television late into the night, and they are always tired the next day;Resident had no knowledge the television having been put on a timer. This is a risk to personal rights of the resident.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
11/12/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241112160946

FACILITY NAME:WINDROSE CARE HOMEFACILITY NUMBER:
496804075
ADMINISTRATOR:SOLOMON, BANAFACILITY TYPE:
740
ADDRESS:1759 WINDROSE LANETELEPHONE:
(707) 852-5025
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 6DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Bana Solomon-AdministratorTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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2
3
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9
Staff yells at residents
Staff does not treat residents with respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/9/2025 at approximately 9:400am, and met with Bana Solomon, Administrator.
LPA reviewed resident files, and staff files. LPA conducted interviews with staff, S1 S2 S3 S4, and other related parties. Reporting party alleges that “staff yells at residents and staff does not treat residents with respect”. The investigation revealed that per staff, S1 S2 S3 S4, interviews, the staff stated to the LPA that they don’t yell and/or disrespect the residents in care Staff stated that they deny having yelled at and/or not shown respect when caring for and/or speaking to the residents in care. Staff interviewed stated they have not observed any other staff person yelling and/or disrespecting a resident in care. Per interviews conducted with other related parties, they have not observed staff to have yelled at residents in care and/or disrespected them when caring for residents or speaking with residents. LPA discussed regulations regarding resident rights/personal rights with staff interviewed. Per investigation, there was not sufficient information obtained to support violations had occurred.
Based on the LPA’s investigation, observations, interviews with staff and other related parties, the investigation, the allegations of “staff yells at residents and staff does not treat residents with respect” are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
No deficiencies cited.
Exit interview was conducted with the Administrator Bana Solomon.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4