496804075-1-31-2025-21-AS-BMOS-DGNUUF-20250514155327

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804075
Report Date: 01/31/2025
Date Signed: 01/31/2025 03:44:21 PM

Unfounded

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
01/30/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250130104628

FACILITY NAME:	WINDROSE CARE HOME		FACILITY NUMBER:	496804075
ADMINISTRATOR:	SOLOMON, BANA		FACILITY TYPE:	740
ADDRESS:	1759 WINDROSE LANE		TELEPHONE:	(707) 852-5025
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 5	DATE:	01/31/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Bana Solomon-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Residents are not served adequate portions of food

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/31/2025 at approximately 1:00pm, and was greeted by caregiver Ana Herron. LPA observd another caregiver, Yaddi, who was also on shift. Administrator Bana Solomon arrived within thirty minutes to meet with the LPA. Reporting party alleges that "residents are not served adequate portions of food". LPA toured the facility. LPA interviewed staff, and other related parties. The investigation revealed that there is a sufficient food supply for resident meals, snacks, and supplies for resident drinks/hydration fluids.. Per interviews with staff (S1, S2, S3), and otherrelated parties, meals are served with appropriate portions, and if a resident wants more they are able to have more. In summary, interviews with other related parties all stated the facility meals are very good, filling, and served in good portions; The related parties that were interviewed all stated, "there were no issues with the meals served at the facility". Per investigation, there was not sufficient information obtained to support violations had occurred.
Based on interviews, LPA observations, and related information obtained during the investigation, the allegation "residents are not served adequate portions of food” is Unfounded". We have found that the complaint allegation (s) was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies cited.
Exit interviews was conducted with Administrator regarding findings of the allegations.
Caregiver Ana Herron signed the report for the Administrator.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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

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
01/30/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250130104628

FACILITY NAME:	WINDROSE CARE HOME		FACILITY NUMBER:	496804075
ADMINISTRATOR:	SOLOMON, BANA		FACILITY TYPE:	740
ADDRESS:	1759 WINDROSE LANE		TELEPHONE:	(707) 852-5025
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 5	DATE:	01/31/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Bana Solomon-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Hazards are accessible to residents in care

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20250130104628

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: 01/31/2025

NARRATIVE

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Per investigation, there is sufficient information obtained to support a violation had occurred.
LPA observed the door leading into the garage unlocked, leaving disinfectants, soaps, cleaners, accessible to residents in care. This deficiency will be cited, 87309(a) Storage Space and Access- 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, see LIC9099D.

During the LPA's tour with staff, the medication closet was observed by the LPA to be unlocked, and all medications were accessible to residents in care.This deficiency will be cited, 87465-(h)(1)(C) Incidental Medical and Dental Care-The following requirements shall apply to medications which are centrally stored: Medications shall be centrally stored under the following circumstances: Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others, 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/Licensee Bana Solomon regarding finding of the allegation and deficiency citations.
Caregiver Ana Herron signed the report for the Administrator.
Appeal Rights were provided to Anna Herron for Licensee Bana Solomon.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250130104628

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: 01/31/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/01/2025 Section Cited CCR 87465-(h)(1)(C)	1 2 3 4 5 6 7	87465-(h)(1)(C) Incidental Medical and Dental Care-The following requirements shall apply to medications which are centrally stored: Medications shall be centrally stored under the following circumstances: Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility,	1 2 3 4 5 6 7	Licensee/Administrator to ensure all the medications are locked and inaccessible to residents in care at all times. Licensee will hold an in-service training on"CentrallyStoring Medications". Submit plan of correction by 2/1/2025.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: During the LPA's tour with staff, the medication closet was observed by the LPA to be unlocked, and all medications were accessible to residents in care. This is a risk to the health & safety of residents in care.	8 9 10 11 12 13 14	Submit proof of training by 2/12/2025. Include trainer, topics, date/time spent, attendees. POC due 2/1/25.
Type A 02/01/2025 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	87309(a) Storage Space and Access- 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.	1 2 3 4 5 6 7	Licensee/Administrator to ensure all cleaner/disinfectants/soaps, items that pose a risk to residents in care are locked and inaccessible to residents at all times. Licensee will hold an in-service training on"Storage space for cleaners/disinfectants/soaps, such items of risk to residents".
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPA observed the door leading into the garage unlocked, leaving disinfectants, soaps, cleaners, accessible to residents in care. This is a risk to the health & safety of all residents in care.	8 9 10 11 12 13 14	Submit plan of correction by 2/1/2025. Submit proof of training by 2/12/2025. Include trainer, topics, date/time spent, attendees. POC due 2/1/25.

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: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

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