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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 06/29/2023
Date Signed: 06/29/2023 02:08:07 PM


Document Has Been Signed on 06/29/2023 02:08 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:KARI OXFORDFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 25DATE:
06/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kari Oxford, Administrator & Ashley Perrone, Resident Care DirectorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Kari Oxford, Administrator and Ashley Perrone, Resident Care Director (RCD). The purpose of this case management inspection is to follow up on an SOC341 & a self reported incident report submitted to Community Care Licensing (CCL) on 6/23/2023.

CCL received a self reported incident report and an SOC 341 form reporting on 6/20/2023 staff (S1) had reported to have witnessed at approximately 4:15 pm an attempted sexual encounter between 2 residents and another individual. SOC 341 was cross reported to law enforcement, ombudsman, and Adult Protective Services.

Residents and Individual were separated and re-directed by staff. POA, PCP, and law enforcement contacted. Facility is working with PCP and responsible parties. Facility has relocated R2 to a different room and increased supervision.



During today’s visit LPA toured facility, obtained documents and was informed by Administrator & RCD that on 6/28/2023 the facility had a meeting with R1's POA regarding additional issues and are working on resident/family support.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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