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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803891
Report Date: 02/27/2025
Date Signed: 02/27/2025 04:13:42 PM

Document Has Been Signed on 02/27/2025 04:13 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:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR/
DIRECTOR:		ERLINDA FERRISFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 49CENSUS: 25DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Erlinda Ferris, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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02/27/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 25 residents in care. Facility approved/cleared for 49 non-ambulatory, of which 10 may be bedridden, and hospice waiver for 20.

At approximately 10:20am, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. Facility has extra food and PPEs located in the garage/storage room.

The main building is two stories. The second building is single story and currently there are three residents, LPA observed a staff member with a resident in the living room area. LPA observed an out of order sign for one of the two washer machines. Per conversation with administrator they have put in a work order for maintenance to come out and replace/fix it. LPA observed all exits doors to have working alarms. LPA observed 1 evacuation chair located around the corner from stairwell #1 but no evacuation chair at stairwell #2 that leads outside the building (Technical Violation Issued). LPA suggested for facility to have a sign up on the wall indicating the location of the evacuation chair for stairwell #1. Department of Social Services will reach out to Fire Marshall's to discuss the placement of the evacuation chairs. LPA observed All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 110.6, 110.3, and 117.7 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 04/2024. Facility has fire sprinklers throughout. Toxins are stored in a locked laundry room. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found 4 out of 5 staff (S1, S3, S4, S5) to be missing required annual and/or initial training (Deficiency Issued). LPA observed S3 to be missing current 1st Aid & CPR certification on file. LPA conducted a review of 5 resident records. LPA observed 2 out of 5 residents (R1 and R2) to not have updated physicians report (Technical Violation Issued).

continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MARIN TERRACE
FACILITY NUMBER: 216803891
VISIT DATE: 02/27/2025
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/27/2025:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Infection Control Plan (review, update if needed)
Emergency Disaster Plan (review, update if needed)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2025 04:13 PM - It Cannot Be Edited


Created By: Anthony Loera On 02/27/2025 at 03:45 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: MARIN TERRACE
FACILITY NUMBER: 216803891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff did not have required training completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Facility to ensure staff receive required number of hours for annual training (identified by their start date). Administrator to create written plan describing how facility will ensure training compliance. Self certification of plan to complete staff training by Plan of Correction due date 3/14/2025.
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.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Anthony Loera
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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