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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 04/14/2026
Date Signed: 04/14/2026 02:52:06 PM

Document Has Been Signed on 04/14/2026 02:52 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
SANTA ROSA RO, 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 BLVDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 55CENSUS: 29DATE:
04/14/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Interim Executive Director, Vivian VillegasTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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04/14/2026; Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met Interim Executive Director, Vivian Villegas. The purpose of the visit was to follow up on a special incident report (SIR) that was self-submitted to Community Care Licensing (CCL).

CCL received an SIR on 04/02/2026, stating that on 03/26/2026 during a med pass observation with pharmacy it was discovered that resident (R1) was out of a couple scheduled meds. Upon further investigation by the facility it was determined R1 had two medications that were last administered on 03/16/2026. A third medication was last administered on 03/20/2026 and a fourth medication was last administered on 03/22/2026.

Per conversation with Resident Care Director, RCD stated when the med techs noticed R1 was running low on medication they started reaching out to R1s doctor via phone who turned out to not be R1s doctor anymore. RCD stated this previous doctor had done a courtesy refill at one point, causing confusion that he was R1s current doctor. RCD stated that there was a miscommunication with R1s family as to who was R1s real doctor, causing a delay in getting medication refills for R1. Once the facility was able to locate R1s real doctor, they were able to get medication refills. RCD stated they were given two wrong doctors before they were able to contact R1s family and receive R1s current doctor.

Although no deficiencies were cited today, facility conducted in-service training and a copy was provided to LPA.

Copy of report and LIC811 (Confidential Names) was provided to Interim Executive Director.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Anthony Loera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2026
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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