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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800977
Report Date: 06/03/2025
Date Signed: 06/03/2025 01:39:47 PM

Unsubstantiated


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
03/19/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250319115051
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 20DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Business Office Director, Ravi BanwaitTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings
Staff did not bathe a resident in care
Staff obtained care giving services for a resident without consent from resident's responsible party
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above allegations and met with Business Office Director, Ravi Banwait as Administrator Lauren Cottman was at annual trainings.

Staff did not safeguard resident's personal belongings- Complainant alleges facility staff lost the resident's electric razor, glasses, and clothing, also they were not labelled and R1 never created an inventory of their personal belongings when they moved into the facility. Investigation revealed Admission Agreement of R1’s personal property and valuables, dated 10/25/2024, only identifies wedding band. Administrator informed that if the facility is advised something has gone missing it will be relayed to the rest of the staff and they will look. Most razors have the residents’ name on them to identify and are put in a box in the med room until using. There is a lost and found box on the 2nd floor med room that keeps glasses and razors, etc… (due to safety purposes all razors are kept in Med room until needed for use). When asked of the brand etc... complainant was unable to provide. Continue on LI9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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 5
Control Number 21-AS-20250319115051
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: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977
VISIT DATE: 06/03/2025
NARRATIVE
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Continued from LIC9099

Complainant looked through box and could not locate any of R1’s alleged missing items. Interview with witnesss (W1 & W2) indicated they were unaware of any missing items or that R1 wore glasses. LPA conducted facility visit on 3/27/2025 and observed R1 to have adequate hygiene. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff did not safeguard resident’s personal belongings is Unsubstantiated.

Staff did not bathe a resident in care- Complainant alleges resident went ten days without having a shower. Follow up interview with complainant informed it was after R1 returned from the hospital in either January 2025 or February 2025 when staff informed it has been 10 days since R1 had a shower due to R1’s refusal to take a shower. Resident progress notes indicated R1 returned from the hospital on 1/23/2025 and had a shower that day. Shower log for R1 indicates they have showers on Sunday’s and Friday AM’s and had one on 1/23/2025 after returning from the hospital, the following shower was given on Sunday 1/26/2025 as scheduled. Refused on 1/31/25 but given on February 2, 2025. Interview with S2 revealed they would mention to the family/POA that there were days where R1 would refuse baths/showers, there was never a time they indicated there had been 10 days since a shower had been given. LPA was informed, if a shower cannot or resident refuses to have a shower on designated shower day’s staff will attempt the follow day and night. LPA conducted interviews, record reviews, and made observations of R1 having satisfactory hygiene. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff did not bathe a resident in care is Unsubstantiated.

Staff obtained care giving services for a resident without consent from resident's responsible party- Complainant alleges after R1 returned to the facility from the hospital on 1/23/2025. The following week the complainant informed they received a phone call that R1 pushed a resident, at which point the facility requested for R1 to be put back on a medication that was recently d/c’d and/or 1:1 staff to be implemented. CCL received SOC341 (2/18/25) (smacked R2 in the chest (female resident) on (2/19/25) hit R2 again, this time on left arm. On 2/14/25 2nd SOC341 R1 pushed R3 (female resident against the med tech office door) Resident agreement references pg 10 paragraph F regarding One on one care “ If it is determined by the Community staff that you are a danger to yourself or others, you may be required to receive one-on-one care and supervision for an additional charge as set forth in Appendix A, or for the cost of all services provided by Outside Provider and billed directly to you. Continue on LIC9099-C2

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

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250319115051
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: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977
VISIT DATE: 06/03/2025
NARRATIVE
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Continued from LIC9099C1

Interview with Administer informed family was advised by Nurse of the possible 1:1 being needed. LPA obtained email correspondence with RP and facility, dated 2/21/2025, email states that R1 due to behaviors requires a 1:1 caregiver. Care conference was held on 2/20/2025. R1 moved out of the facility 4/11/2025. Based on interviews conducted and record review, the facility communicated R1’s care needs with RP prior to implanting. Therefore, the allegation Staff obtained care giving services for a resident without consent from resident’s responsible party is UNSUBSTANTIATED.

A finding of Unsubstantiated means, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents

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

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/19/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250319115051

FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 20DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Business Office Director, Ravi BanwaitTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff did not allow resident's responsible party to use a medical pharmacy of their choice
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above allegations and met with Business Office Director, Ravi Banwait as Administrator Lauren Cottman was at annual trainings.

Staff did not allow resident's responsible party to use a medical pharmacy of their choice --Complainant alleges facility is using a pharmacy, of their choice and not the one that they wanted to use. This family normally picks up medication from Resident’s own pharmacy and deliver to the facility and wanted to continue to use this pharmacy. Investigation revealed, with LPA’s follow up call with Complainant, the facility did not let reporting party know when R1 was getting low on a medication. When the family learned about it, they got it right away. The facility had already obtained the medication from there pharmacy, although facility ended up paying for it, never charging the family. Based on interviews conducted and records reviewed and obtained, the allegation Staff did not allow resident’s responsible party to use a medical pharmacy of their choice is UNFOUNDED. Continue on LI9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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 5
Control Number 21-AS-20250319115051
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: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977
VISIT DATE: 06/03/2025
NARRATIVE
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Continued from LIC9099-A

This agency has investigated the complaint alleging staff did not allow resident’s responsible party to use a medical pharmacy of their choice. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents

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

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5