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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803891
Report Date: 03/10/2026
Date Signed: 03/10/2026 03:37:32 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
01/26/2026 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20260126092155
FACILITY NAME:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:KATHLEEN DEVERAFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: 20DATE:
03/10/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kathleen Devera (Administrator)TIME COMPLETED:
03:52 PM
ALLEGATION(S):
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-Staff mismanaged resident medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Kathleen Devera, Administrator.

An allegation regarding staff mismanaged resident medication. The Reporting Party stated that the facility is not documenting of medications administered, both routine and PRN including antipsychotics and opioid medications, bowel movements, objective findings during the care of R1, then for at least a week upon admission, staff were unable to secure appropriate medications and monitoring equipment, such as glucometer, that were prescribed to R1 after been discharged from the hospital. Based on interviews conducted with Administrator and facility medication technician (S6), they acknowledge that R1 has a diagnosis of diabetes, they confirmed that they received on 12/30/25 R1’s one touch glucometer, lancing device, test strips, but no lancets and R1 is unable to check their own glucose, but the facility has not been provided with a glucose check order to monitor R1’s daily glucose levels, which it was reported to home health nurse once. Continue on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
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
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
01/26/2026 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20260126092155

FACILITY NAME:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:KATHLEEN DEVERAFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: 20DATE:
03/10/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kathleen Devera (AdministratorTIME COMPLETED:
03:52 PM
ALLEGATION(S):
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-Sexual Assaut.
-Personal Rights.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Kathleen Devera, Administrator.

The Department received an allegation of sexual assault. According to the Reporting Party on 1/23/26, resident (R1) stated that they were sexually assaulted (unknown date) and raped by a staff (unknown name) allegedly this happened during incontinent care (unknown date) several days ago, but R1 is unable to recall a specific location/room, date, time of the incident took place or produce the name or role of accused perpetrator, and only stated it was witnessed by another person (unknown name) who said "I saw that, stop that". During the course of this investigation, The Department investigator conducted interviews with staff, residents and other witnesses, and reviewed records associated to the involved resident (R1). Based on interviews conducted and records obtained the investigation revealed insufficient evidence to support this allegation, R1 was unable to describe where or when staff sexually assaulted them, identify a suspect or witness, or provide corroborating information to support the allegation. Continue on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260126092155
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: MARIN TERRACE
FACILITY NUMBER: 216803891
VISIT DATE: 03/10/2026
NARRATIVE
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Continued from LIC9099 A...
However, the facility provided resident’s records review, where there was an entry date 1/19/26 at 2:09pm indicates that R1 reported to staff (S1, S2 & S3) the alleged “abuse”, but the facility did not follow up on it. Also, on 12/12/25 there was another incident involving another resident (R2) where it was reported to facility management that staff (S4) was no longer welcome to care for R2 due to their incompetency when providing care and been always in a rush, getting defensive and other complaints that other staff raised about them, which resulted in management conducted an internal investigation and provided a written warning. LPA reviewed incident reports submitted to the Department and there were no incident reports regarding any of these reports. LPA will address in case management deficiencies discovered. A finding that the complaint allegation occurs of sexual assault is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Another allegation of Personal Rights was received. Per Reporting Party, the facility staff withheld R1’s phone and refused to allow them to use the facility phone. On 1/26/26 and 2/27/26, LPA conducted 10-day visit and subsequent visit to investigate this allegation. Based on LPA’s interviews conducted with staff (S5 & S6) and residents (R1, R2 & R3) in care who are residents that carry their own cellphone with them stated that they maintain their devices handy and expressed that staff help them when they are unable to make a phone call, but there were no concerns regarding refusal to allow them to use the facility phone. Although staff interviewed revealed that residents have a history of dialing 911 constantly for non-emergency reasons. Based on records review, LPA requested service calls from Mill Valley Police Department for the month of December 2025, and January 2026 confirmed assistance provided by medical agencies needed and couple of wellness checks conducted on 12/24/25 and 12/26/25, but no areas of concern were determined after visits. Based on LPA’s observations during interviews conducted with R1, R2 & R3, they were able to locate their phones in their pockets or their drawers located next to their beds. Based on LPA’s observations, interviews and records review there was no supporting evidence to indicate that the violation could have happened at a prior date. A finding that the complaint allegation occurs of personal rights is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20260126092155
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: MARIN TERRACE
FACILITY NUMBER: 216803891
VISIT DATE: 03/10/2026
NARRATIVE
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Continued from LIC9099...

Based on records review, R1’s physician report dated 12/23/25 and care plan address the need for a special diet due to glucose control needed, confirms that R1 is unable to perform own glucose testing. As of today, the facility did not follow up with R1’s physician or home health to obtain glucose check order and R1 has not been monitored their glucose levels since they were admitted back on 12/24/25. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260126092155
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: MARIN TERRACE
FACILITY NUMBER: 216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2026
Section Cited
CCR
87628(a)
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87628(a)Diabetes: licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens. This requirement is not met as evidenced by:
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The Administrator agrees to ensure blood glucose testing is performed by an appropriately skilled medical professional or contact R1’s physician for current blood glucose order and submit plan to CCL to ensure a skilled medical professional is performing the test by POC due date.
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Based on interviews & file review the licensee failed to ensure that resident (R1) was retained at the facility while not able to perform a glucose testing as per physician's report, but the facility did not followed up more than once to ensure R1’s glucose levels were monitored, which poses an immediate risk to the health and safety of 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: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5