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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804150
Report Date: 02/21/2025
Date Signed: 02/21/2025 11:38:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/19/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250219092309
FACILITY NAME:WINDSONG OF SONOMAFACILITY NUMBER:
496804150
ADMINISTRATOR:JOHN BELTZFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRIVETELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 78DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elizabeth Alfaro, Buisness Office ManagerTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not issue a refund to resident's authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility to open complaint investgation and delivered complaint findings. LPA met with Business Office Manager (BOM) Liz Alfaro as Administrator was out of the building.

LPA investigated the above allegation. During the investigation LPA requested and obtained copies of documents and conducted interviews.

The following was reported to The State of California Department of Social Services (DSS), Community Care Licensing Division (CCLD), Santa Rosa Regional Office:

Continue on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
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 3
Control Number 21-AS-20250219092309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150
VISIT DATE: 02/21/2025
NARRATIVE
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Continued from LIC9099

Responsible parties (who paid in advance) of deceased resident has not received a refund check as required. Resident (R1) passed away at the beginning of January, 2025, it has been over a month and they did not receive their refund check.


Allegation - Licensee did not issue a refund to resident's authorized representative : Interviews conducted with Business Office Manager and other parties revealed. There was a laps of approximately a month and a half in processing of refund due to it falling through the cracks on my end and somewhere on accounting's end. Review of records revealed Move out was 1/14/2025, request for refund was sent to accounting 1/30/2025. On 2/21/2025 records show facility sent refund check, although BOM is waiting for response from accounting of confirmation. Staff stated they did not know regulation requires refunds to be paid within 15 days of when the resident's belongings are removed from the facility after move out or death.

This agency has investigated the complaint alleging "Licensee did not issue a refund to resident's authorized representative Based on record review and interviews conducted, licensee did not pay the refund to the resident's Responsible Party within the required 15 days after the removal of resident's belongings, therefore the preponderance of evidence standard has been met, the above allegation is found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250219092309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
HSC
1569.562(c)
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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
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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
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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.
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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: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
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