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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 09/17/2021
Date Signed: 09/17/2021 12:17:44 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: 31DATE:
09/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Brittany Karlinski AdministratorTIME COMPLETED:
12:17 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection. LPA arrived to the facility and met with Administrator Brittany Karlinski. The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL) on 9/1/2021.

CCL received an incident report, submitted on 9/1/2021 Staff (S1) alleged Resident (R1) being pushed by (S2). Incident Report submitted to community Care Licensing (CCL) on 09/02/2021 reported the following: During a painting activity, R1 had paint on their face and S2 attempted to clean the paint off of R1's face. Upon further investigation it was determined R1 became agitated by S2 attempting to clean the paint from R1's face and R1 pushed S2.
Administrator stated they conducted an internal investigation and will provide training on reporting requirements to staff.

LPA conducted interviews and gathered information

No deficiencies were issued during today's inspection

Exit interview conducted with Brittany Karlinski Administrator
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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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