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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 01:42:08 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
03/24/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250324084022
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:LAUREN COTTMANFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 20DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Business Office Director, Ravi BanwaitTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff are not meeting resident’s incontinence care needs
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.

Complainant alleges facility staff are not meeting the resident’s incontinence care needs. Complainant alleges on 3/20/25 and 3/21/25, midafternoon resident was observed in “Depends” that were "completely saturated" with urine. Reporting party stated it had to have been several hours since staff had changed resident. As well, on 3/20/25, resident's bed linens were "soaked with urine" and had to be changed. Documents obtained from facility: Care appraisal dated 2/16/2025 of toileting -requires prompting/assistance with toileting but can be left alone, (progress notes) of daily routines for R1 (3/20/2025 & 3/21/2025) do not indicate R1’s bed had been urinated in or had depends full of urine.
Continued 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 2
Control Number 21-AS-20250324084022
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

LPA interview of witness’ (W1 & W2) revealed R1 is able to use the bathroom on own and other than observing some remnants of urine on R1’s shirt or pants after using the restroom, neither W1 or W2 have observed R1’s bed urinated in or R1 wearing urine-soaked adult briefs. LPA conducted facility visit on 3/27/2025, observed R1’s room not having mal odors/no urine smell and R1 to have adequate hygiene. There was no information obtained that supported a violation had occurred.

Based on record review, interviews conducted, and observations made, the allegation facility staff are not meeting the resident’s incontinence care needs is UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is 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: 2 of 2