216800977-7-24-2023-21-AS-HDBI-CUBRPG-20230802131156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800977
Report Date: 07/24/2023
Date Signed: 07/24/2023 04:17:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
05/30/2023 and conducted by Evaluator Victoria Bertozzi

COMPLAINT CONTROL NUMBER: 21-AS-20230530111633

FACILITY NAME:	WINDCHIME OF MARIN		FACILITY NUMBER:	216800977
ADMINISTRATOR:	KARI OXFORD		FACILITY TYPE:	740
ADDRESS:	1111 SIR FRANCIS DRAKE RD		TELEPHONE:	(415) 482-4100
CITY:	KENTFIELD	STATE: CA	ZIP CODE:	94904
CAPACITY:	55	CENSUS: 25	DATE:	07/24/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Administrator, Kari Oxford; Resident Care Director, Ashley Perrone		TIME COMPLETED:	04:26 PM

ALLEGATION(S):

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Facility failed to ensure resident takes their medications as prescribed by their Physician

INVESTIGATION FINDINGS:

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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Kari Oxford and Resident Care Director, Ashley Perrone.

Facility failed to ensure resident takes their medications as prescribed by their Physician – Complaint alleges that facility failed to ensure resident was assisted with medication refill causing them to not have medication for two weeks. Per file review and interview, the resident's primary physician was not identified on the Indentification and Emergency Form or the Physician's Report. Attempts to get medication from the responsible party were not successfull. Attempts to clarify who the resident's primary physician was and gain new prescriptions per facility policy were also unsuccessfull despite multiple attempts by the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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