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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 06/25/2021
Date Signed: 06/25/2021 02:32:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:BRITTANY KARLINSKIFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 63DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Interim Executive Director, Tony IbarraTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs) Farhaan Sarangi and Erik Gonzalez-Campos arrived unannounced to conduct a Required – 1 year inspection of the facility. LPAs were welcomed by front desk staff who directed LPAs to sanitize hands, screen for symptoms, and sign-in on the visitor sheet. Front desk contacted Interim Executive Director, Tony Ibarra for the visit. Facility currently has 63 residents.

LPAs conducted walk through of the facility beginning at 1:15 PM with Tony Ibarra. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on October 2020.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPAs observed kitchen staff improperly wearing a mask and not using gloves. LPAs provided guidance to remind staff to use gloves and wear masks.



Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There is supply of cleaners, hygiene products and paper products available for residents.

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if there are symptoms of COVID-19 + in the facility. Disaster Drills were conducted June 2021. LPAs reviewed and approved the Mitigation Plan during the visit. Facility staff have been N95 Fit tested. Personal Protective Equipment is sufficient.

No deficiencies were cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to Interim Executive Director, Tony Ibarra.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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