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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800977
Report Date: 10/30/2025
Date Signed: 10/30/2025 02:08:00 PM

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
09/09/2025 and conducted by Evaluator Shannan Hansen
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250909105915
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:LAUREN COTTMANFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE BLVDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 27DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lauren Cottman, AdministratorTIME COMPLETED:
11:03 AM
ALLEGATION(S):
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Facility staff are not meeting resident care needs
Responsible party not notified of resident fall
Facility staff not giving prescription medications as prescribed by doctor
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 Administrator, Lauren Cottman.

During investigation LPA made 3 visits (9/18/25, 10/14/25, & 10/30/25), conducted 11 interviews with staff and outside parties, made observations and reviewed records.

Facility staff are not meeting resident care needs -- Reporting party alleges resident has not had a shower since they were admitted, general lack of care of patient and lack of activities. R1’s pre-placement appraisal signed by Administrator on 8/26/2025 indicates, needs help with bathing, hair care, personal hygiene. Care appraisal dated 8/19/2025 completed by RCD indicates- requires assistance from one (1) person two times a week for bathing. Record review revealed facility did not have a shower log indicating when R1’s showers were scheduled for, days of the week, and times, or any shower sheet that indicates if there is a skin problem/break down of skin/injury, etc. Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
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-20250909105915
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: 10/30/2025
NARRATIVE
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Continued from LIC9099:
Interviews with 3 staff (S1, S2, & S3) who care for residents on 3rd floor revealed none of them had given R1 a shower/bath, for the approximate 3 weeks R1 was at facility. Interview with R4 revealed protocol is, when a resident is admitted to the facility, staff put them on a shower schedule 2 times a week (unless otherwise requested) and then sign log each time a shower is given or indicate a refusal or indicate refusal in daily notes, which was not completed in this case. There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "facility staff are not meeting residents’ care needs", therefore, the allegation is Substantiated.

Responsible party not notified of resident fall- Reporting party alleges facility did not notify/call responsible party of residents fall until in person, hours later when resident was at the hospital. Incident report received indicates facility was aware at approximately 7:45 am but POA/Responsible Party told in person at 10am when arrived at facility for regular visit.

Interview with S5 informed the processes of inputting new resident information: obtain residents information from POA then S5 types it up on Emergency contact forms (attachment #5) & Resident & responsible party information form (attachment #6) etc. then provide to RCD their portions who then implements into their computer system. Documents obtained revealed the Identification document handwritten from the POA is the same on the emergency contact form but on the responsible party information form the last number of the phone number was turned from 9 to 3. S4 typed in the number from the responsible party information which was wrong as indicated on the facility online resident contact number for their POA. 9/11/25 at 10am Progress Notes & Incident report submitted to CCL on 9/16/25 of 9/11/25 incident for R1 indicates Med Tech called POA 3 times starting at 7:45am not getting any answer and finally left a message. Progress notes also indicated S4 notified POA at 10am when they came into the facility to visit. Interview with S1 informed when there is a fall or emergency and they need to contact the family they go to the online information. Investigation revealed S1 called R1’s POA when incident occurred on 9/11/2025 at approximately 7:45am, although they were dialing the wrong number that had been inputted into the computer for the responsible party. On 9/22/25 responsible party informed LPA, they also never received any written notification of incident. Regulation 87211(a)(1)(D) indicates :Reporting Requirements: Each licensee shall furnish ..A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident. Continue on LIC9099C2

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

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250909105915
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: 10/30/2025
NARRATIVE
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Continued from LIC9099C:

There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "responsible party not notified of resident fall". Therefore, the allegation is Substantiated.

Facility staff not giving prescription medications as prescribed by doctor- Reporting party alleges facility may not have been giving R1 the correct dosages of medications that were prescribed by physician. Facility only had paper Medication Administration Record (MAR) of August for R1 which indicated prescription Rexulti was to be given every AM although does not show was given 8/29- 31/2025. Further review of medications indicated 10 of R1’s daily medications from 8/28-31/2025 were not given consistently. LPA interview with S4 revealed R1 did not have any medication refusals. Interview with Med tech and Administrator informed, with the documents provided they could not confirm medications were provided on said days. As there was no proof medications were provided to the resident, there is sufficient information obtained to support that a violation has occurred regarding allegation Facility staff not giving prescription medications as prescribed by doctor is SUBSTANTIATED.

Additionally, Community Care Licensing (CCL) received an incident report on 10/20/2025 indicating on 10/14/2025 while inputting narcotics into new EMAR system discovered R2 had discrepancy in log record. From 8/18/2025 to 10/13/2025 (except on 6 correct occasions) multiple PM med techs had inadvertently been giving R2 PRN Geri-tussin instead of physician ordered routine Guaifen-Codeine. No adverse side effects observed, Responsible party and Hospice physician notified.

A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of evidence standard has been met.

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: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20250909105915
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87464(f)(4)
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87464(f)(4). Basic Services. Basic services shall at a minimum include:...Personal assistance and care as.. indicated in the pre-admission appraisal, …such as dressing, eating, bathing..***Based on documents reviewed and interviews conducted, this requirement was not met as evidenced by:
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 Administration to provided refresher training to staff on the subject of showers provided to residents regarding Regulations 87464(f)(4) and submit by 10/31/2025 type of training and date training will be conducted. Logs and scope of training with signatures to be submitted to CCL/LPA by 11/7/25 to clear citation.
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Care report-appraisal for 8/26/2025 indicate R1 was to have 2 showers per week although, there were no shower logs for time frame or notes indicating shower refusals, along with 4 staff interviews indicated R1 not showered 8/26 thru 9/11/2025. This posed an immediate risk to the health and personal rights of R1
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Type B
11/07/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident...
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Facility Administrator agrees to have staff who are responsible for inputting contact information and reporting incidents, complete an in-service training regarding regulation 87211 no later than POC due date, 11/7/2025 and submit a copy of signed and dated log.
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This requirement has not been met based on document review and interviews revealing due to facility writing wrong number of responsible party they were not reached, as well responsible party indicated they never receive written notice of incident report. This is a potential risk to residents in care.
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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: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20250909105915
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care:(a)A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review, Licensee did not
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Licensee provided proof of training that was conducted on 10/16/2025 on "The Six Rights", central storage of medications, & medication destruction process when an order is discontinued, for all med techs that administer medications.
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comply with the section cited above and did not ensure that medication was administered to R1 as required. R2 Incident Report stated that PM Med Tech provided wrong medication ??times. This is an immediate health and safety risk to residents in care.
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Deficiency cleared during visit.
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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: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5