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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 07/24/2025
Date Signed: 07/25/2025 07:54:08 AM

Document Has Been Signed on 07/25/2025 07:54 AM - 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:		LAUREN COTTMANFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 55CENSUS: 26DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Lauren Cottman, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection of this 3 story 36 apartment (some shared) RCFE with a plan of operations for Dementia and was greeted by staff. LPA met with Administrator Lauren Cottman and Business Office Director (BOD) Ravi Banwait. The facility has a fire clearance approved for 55 Nonambulatory residents on the 2nd and 3rd floors with magnetic locked egress doors and gates on all patios and levels, last effective date of 8/20/2019. A Hospice Waiver approved for 12. There is a total of 26 residents of which 4 are under Hospice care.

At approximately 8:45AM, LPA toured the community with staff & BOD. The tour of the facility included ten resident apartments, activity rooms, salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstruction. Delayed egress doors have audible alarms when doors are opened without access codes. Facility serves residents with dementia and has special care plan of operation and programming. Hot water temperature measured between 115.3 degrees F and 121.2 degrees F not within regulation of 105 to 120 degrees F in six of ten rooms tested (see LIC809D). Bathrooms contained necessary grab bars and slip-resistant mats, strips, or flooring in all bathtub and or shower floors as required by Title 22 Regulations. There was a supply of cleaners, hygiene products and paper products available for residents. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchenettes were inspected. Menus with snacks and beverages are available to residents. Activity schedules are posted and at approximately 9am LPA observed activities director conducting morning activity and at approximately 4pm observed live music being played for monthly birthday party.

Continue on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/25/2025 07:54 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Shannan Hansen On 07/24/2025 at 03:28 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation (see pics) Housekeeping closet was found unlocked with toxic cleaning chemicals including Mold Armor Rapid clean remediation & R3 room LPA observed unlocked bathroom cabinet with razors and supplies (see pics) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Licensee or Administrator will provide an LIC 9098 Proof of Corrections self certifying that CCR Regulation 87309(a) was reviewed with all Memory Care staff by POC due date of 5/7/2025.
Under Appeal
Type A
Section Cited
CCR
87468.2(a)(4)
87468.2 Additional Personal Rights...(a) In addition to the rights listed in Section 87468.1...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications,

This requirement is not met as evidenced by:
Deficient Practice Statement
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and competency to meet their needs. This requirement not met by licensee as evidenced by: Based on LPA observations, interview and record review, facility is not meeting resident's needs having only 1 caregiver on each of the 2 floors of 26 dememtia residents (10 two person assist & 16 1 person assist) and only 1 med tech, which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Licensee /Administrator will submit plan of how they will cover the amount of residents having multiple needs (10 two person assists) by making sure there are 4 caregivers (2 on each floor) for AM and PM shifts. Not including Med tech and or RCD. Will submit POC to LPA by end of 7/25/2025 to clear POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2025 07:54 AM - It Cannot Be Edited


Created By: Shannan Hansen On 07/24/2025 at 03:28 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Administrator's observation, record review and interview the licensee did not comply with the section cited above in not finding any records indiating attached to smoke detection system or carbon monoxide detectors in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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LIcensee or Administrator to obtaine carbon monoxide detector and put in facility. Administrator will be putting in one on each level and submit to LPA receipt and pictures with self certification they understand the regulation by POC due date of 8/1/2025 to clear citation.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 6 out of 10 resident bathroom faucets were not within regulation temp of 105 to 120 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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Licensee or Administrator to submit 5 day water log of residents bathroom water facuets showing temperature within range and submit to LPA by POC due date of 8/1/2025 to clear citation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2025 07:54 AM - It Cannot Be Edited


Created By: Shannan Hansen On 07/24/2025 at 03:33 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)

87458 Medical Assessment: (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, Licensee did not ensure R4 received a medical assessment prior to admission. This poses a potential Health, Safety or Personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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Licensee shall submit self certification they have read and understand Regulation 87458. Self certification shall be submitted to CCLD by 08/1/2025 to clear citation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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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: 07/24/2025
NARRATIVE
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Continue from LIC809
LPA was informed there was only 1 med tech and 2 caregivers for entire facility during morning shift of 26 residents of which 10 are two person assist and 16 one person assist which is a violation of personal right 87468.2(a)(4) see LIC809D. Facility has multiple indoor and outdoor sitting areas and a private dining area. Toxins are stored in a locked laundry and housekeeping closet; although at approximately 9:15am Housekeeping closet was found unlocked with toxic cleaning chemicals including Mold Armor Rapid clean remediation (see pics & LIC809D). Also in resident (R3’s) room LPA observed unlocked bathroom cabinet with razors and supplies (see pics). A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing.

A sample review of six resident & five staff records as well as three resident’s medications was conducted. LPA reviewed resident’s files at 10:45 AM on 7/24/2025 and learned that 6 out of 6 residents have an updated reappraisal/needs & care plan on file. Medical assessments of 1 out of 6 residents was absent during inspection, as required by Title 22 Regulation (see LIC809D). In addition, as per ED facility has no residents with pressure sore as of 7/24/2025.

Medications were centrally stored in a locked medication cart in the facility medication room. The Medications of 3 out of 3 residents were found to be given according to physicians’ directions on 7/24/2025 at 10:20 AM. Centrally Stored Medication Record (CSMR) of 3 out of 3 residents were found to be accurate.

LPA conducted a sample review of staff records at 1:15 PM on 7/24/2025 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification for all staff. Lauren Cottman Administrator Certificate # 7028976740 expires 9/21/2026.

Fire Extinguisher was found to be last charged on 9/10/2024 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 4/14/2025. LPA & Administrator were unable to locate Carbon monoxide detectors or records indicating they were attached to smoke detector system (see LIC809D). There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur.

Continue on LIC809C2

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 6 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: 07/24/2025
NARRATIVE
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Continued from LIC809C

In addition, LPA advised to ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted monthly in different shifts with the last one on 6/6/2025.

Appeal of Rights Given.

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 8/14/2025:

LIC 308 Designated
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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