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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 08/09/2023
Date Signed: 08/09/2023 10:45:24 AM


Document Has Been Signed on 08/09/2023 10:45 AM - 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: 28DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Kari Oxford, Administrator & Ashley Perrone, Resident Care DirectorTIME COMPLETED:
10:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Resident Care Director (RCD) Ashley Perrone & Administrator, Kari Oxford who arrived later. The purpose of this case management inspection is to follow up on an, SOC 341 submitted to Community Care licensing (CCL).

CCL received an SOC 341 form on 8/9/2023 reporting on 8/5/2023 outside agency staff (S1) was witnessed by S2, strike resident (R1) on the side of head with a closed fist. Facility contacted Law Enforcement who took custody of S1 and removed from facility. Facility is full dementia.

During today's inspection LPA was informed by Administrator & RCD that S1 worked at the facility on call since April, 2023. LPA informed Administrator & RCD that S1 is not associated to facility and should never be working and providing care to residents prior to a criminal record clearance or exemption ***Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance/transfer per two weeks for a total of $500.

LPA conducted interviews, obtained records, and advised facility to submit a copy of police report when received. LPA will review information, conduct additional interviews and follow up with facility.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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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Document Has Been Signed on 08/09/2023 10:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2023
Section Cited
CCR
87355(e)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
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Law Enforcement removed staff (S1) from the premises and facilty will not schedule S1 again. Licensee will submit a self-certification LIC9098 ensuring that regulation was understood to CCL by POC due date.
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Based on LPA record review and interview with Administrator & RCD facility did not ensure to obtain a criminal record clearance for staff (S1) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care.
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***Civil Penalty is being assesed for the amount of $500.

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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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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