216800977-1-29-2026-21-AS-MCUA-DQSUG3-20260129143339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 01/29/2026
Date Signed: 01/29/2026 02:33:56 PM

Document Has Been Signed on 01/29/2026 02:33 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 MARIN		FACILITY NUMBER:	216800977
ADMINISTRATOR/ DIRECTOR:	LAUREN COTTMAN		FACILITY TYPE:	740
ADDRESS:	1111 SIR FRANCIS DRAKE BLVD		TELEPHONE:	(415) 482-4100
CITY:	KENTFIELD	STATE: CA	ZIP CODE:	94904
CAPACITY: 55		CENSUS: 33	DATE:	01/29/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:06 PM
MET WITH:	Lauren Cottman (Executive Director/Administrator)		TIME VISIT/ INSPECTION COMPLETED:	02:50 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	Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Lauren Cottman. The purpose of the visit was to follow up on a SOC341 report that was submitted to Community Care Licensing (CCL) on 1/23/26. Per SOC341, on 1/21/26 at approximately 6:30pm, resident (R1) approached resident (R2) touched their shirt, R2 verbalized their dislike and shoved R1 to the floor causing them to hit the back of their head. They were immediately separated by staff. EMS initiated and assessed R1 for injury, R1's responsible party declined transport. Both residents have been placed on alert charting for 48 hours. R2's care plan has been updated. Responsible parties were notified. During today's visit, LPA reviewed resident's records. Based on records review, R2's physician report dated 9/25/24, R2 does have a cognitive condition, but they don't have a history of aggressive behavior. Although, R2 receives frequent visits from a third party agency who indicated in their log dated 11/13/25 that they have noticed some concerns including behaviors and recommended further discussion with R2's responsible party before making any adjustments to antidepressant, which it was reflected in R2's 90-day care plan assessment dated 12/10/25. According to care plan, R2 has active behavioral issues requiring staff to be alert to triggers that could increase behaviors such as noise or crowded areas. On 1/22/26, the facility implemented a behavioral engagement log to identify any trigger situations to obtain more data, one-on-one engagement walks and outing were incorporated to help the resident with behavior issues. Additionally, R2's physician have made adjustments to some of R2's medications. According to Administrator, care plans were not updated for any of the residents because they have implemented the behavioral engagement. Regarding R1, LPA learned that the facility staff called the paramedics 911 immediately, they arrived, assessed R1 and they did the vitals, and reported to R1's responsible party who denied to transport R1 to the hospital for further evaluation. Based on records review and interviews, the facility have followed their protocols. No deficiencies were cited during today's case management visit. Exit interview conducted with the Administrator and copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

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 2

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)

Page: 2 of 2