<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 05/30/2024
Date Signed: 05/30/2024 02:57:07 PM

Document Has Been Signed on 05/30/2024 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR/
DIRECTOR:		MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 55CENSUS: 26DATE:
05/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Ravi Banwait, Business Office DirectorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
License Program Analyst (LPA) Shannan Hansen arrived at 8:45 AM to complete an unannounced annual inspection and met with Mary McClure, Administrator. There is a total of 26 memory care residents.

During inspection 5/29/24 LPA observed 3rd floor west fire exit obstructed by bedframe across interior of both exit doors, and a full bed in front of one of the exit doors on the east side of the 3rd floor, which is a violation of Fire Safety regulation 87203 (see pics & LIC809-D). During today’s inspection 5/30/2024 both bed & bedframe have been removed. During inspection on 5/29/24 at approximately 9:30am LPA observed unwrapped quiche in 3rd floor kitchenette drawer, unwrapped/uncovered ice cream in freezer & uncovered pie from previous day in refrigerator (see pics LIC809-D). LPA also observed on 3rd floor, black coloring on floor under kitchenette sink where water leak use to be, a missing bedroom door to room 314 & bathroom wall to resident (R1)’s room (see pics & LIC 809-D). Razors & a pair of scissors were observed by LPA & BOD on 5/29/2024 at aprox 9:45 am in R2’s unlocked bathroom cabinet. BOD moved immediately (see pics & LI809-D).

At approximately 11:30 pm, LPA reviewed 5 staff records. 2 of 5 staff Dementia training records were not complete & 2 of Medication training records did not contain required hours of training (see LIC 809-D) Evidence of current first aid and CPR training were present for required staff. All staff had required criminal record clearance and were associated.



LPA reviewed centrally stored medication records of 2 of 2 residents finding to be complete to complete this annual inspection.

Continued on LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 05/30/2024 02:57 PM - It Cannot Be Edited


Created By: Shannan Hansen On 05/30/2024 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed razors & a pair of scissors and other sharp objects in an unlocked resident bathroom cabinet accessible to residents in care along with a 5 gallon bucket of pain in unlocked staff room in kitchenette. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
1
2
3
4
Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 5/1/2024, and Training to be submitted by due date of 6/13/2024.
Type A
Section Cited
CCR
87203


87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation (see pics), licensee did not comply by having a bed frame on 3rd floor east side emergency exit door, restricting ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500.
POC Due Date: 05/31/2024
Plan of Correction
1
2
3
4
Administrator to send in written statement indicating that they understand regulation 87203 and will ensure future compliance -as proof of correction by POC due date 5/31/2024. Beds have beds have been removed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/30/2024 02:57 PM - It Cannot Be Edited


Created By: Shannan Hansen On 05/30/2024 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Two (2) staff lack proof of required annual training, per LPA's file reviews, the licensee did not comply with the section cited above in two out of five files reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
1
2
3
4
Licensee to ensure all four direct care staff obtain required annual training; Submit proof of training by POC due date of 6/13/24.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
LPA observed food, half a quiche uncovered in kitchenette drawer, accessible to residents in care, & unwrapped/uncovered ice cream in freezer & uncovered pie from previous day in refrigerator . This is a risk of resident's health & safety and/or a personal rights risk to residents in care.
POC Due Date: 06/13/2024
Plan of Correction
1
2
3
4
Licensee to ensure that the facility is following regulations, and that cold food items are kept cold at appropriate temperature, and hot foods are kept at appropriate hot temperature and covered. Licensee to ensure food is also safe for resident consumption. Licensee to submit how the food service will be handled regarding residents picking up their meals and/or having their meals delivered where the food is kept healthy and safe to serve to residents in care.Submit policies and procedures on the above. Plan of correction is due 6/13/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/30/2024 02:57 PM - It Cannot Be Edited


Created By: Shannan Hansen On 05/30/2024 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(d)
Care of Persons with Dementia
(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 water heating food warmers in 2nd & 3rd floor dementia facility kitchettes were not secured from residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
1
2
3
4
Administrator to enclose or remove food warming devices in both kitchenettes and submit proof by 6/13/2024 with a written statement of understanding of regulation 87705(d).
Type B
Section Cited
HSC
1569.69(b)

1569.69(b)Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Two (2) staff lack proof of required HSC 1569.69(b) medication training, per LPA's file reviews, the licensee did not comply with the section cited above in two out of five file reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
1
2
3
4
Licensee to ensure that all staff obtain the H&S Code annual medication training as required; Submit proof of the staffs, four (2), medication training by POC due date of 6/13/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977
VISIT DATE: 05/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Fire extinguishers were last serviced 9/25/2023. Fire safety system including smoke detectors and carbon monoxide detectors are checked quarterly by facility staff and are on a regular service schedule with a vendor, is current. Disaster Drill are conducted monthly in shift rotation with the last drill being conducted on 5/22/2024.

Facility is being cited today for 87203 Fire Safety violation with an immediate Civil Penalty in the amount of $500.

The following deficiencies were observed (see LIC 809D) 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..

LPA Hansen is requesting Licensee to update and submit the following documents by 6/13/2023 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 610 Emergency Disaster Plan (if changes)

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/30/2024 02:57 PM - It Cannot Be Edited


Created By: Shannan Hansen On 05/30/2024 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087(a)Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
*Based on observation facility did not maintain facility in good repair by: 3rd floor, black coloring on floor under kitchenette sink where water leak use to be, a missing bedroom door to room 314 & bathroom wall to resident (R1)’s room at all times through out of the facility which poses a potential health, safety risk to clients in care.
POC Due Date: 06/13/2024
Plan of Correction
1
2
3
4
Licensee must maintain the facility clean, safe, sanitary, and in good repair at all times. Facility agrees to ensure that the entire facility will be clean and in good repair at all times. Facility to fix flooring under kitchette, bedroom door, bathroom wall to R1's room. Administrator to submit an LIC 9098 self-certification that facility is in good repair to CCL by POC date of 6/13/2024 and pictures of corrected issues in order to clear the deficiency.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 7 of 7