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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:22:15 PM


Document Has Been Signed on 12/14/2023 12:22 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: 26DATE:
12/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kari Oxford, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a case management on mandated reporting requirements at facility and was welcomed by staff Maryellen. Administrator Kari Oxford was contacted and arrived an hour and a half later.

On 12/8/2023 Community Care Licensing (CCL) received information from an outside agency involving resident (R1), being assaulted by a caregiver. The facility has not notified licensing agency as required by regulation 87211(a)(1)(D), within 7 days of incidents.

LPA was informed by Administrator, CCL had not been provided required SOC 341 documentation due to lack of communication within facility.

LPAs interview with administrator and additional documents obtained regarding incident and involved parties, learned agency caregiver/individual (I1) had worked at facility for approximately three months with November 27, 2023 being the last day at facility. LPA located I1 on guardian check list, showing I1 has not been background cleared by DOJ. LPA is issuing citation for not having I1 background cleared by DOJ 87355(e)(1).

Based on records review, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Last incident report submitted 11/21/2023. Administrator could not provide proof that incidents were reported to CCL.

*****Civil Penalties for $500.00 for not having DOJ clearance of Individual/Caregiver

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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/14/2023 12:22 PM - 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: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
87211(a)(1(D)

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87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident...
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Licensee shall submit an LIC 9098 understanding the regulation. Licensee shall submit a Plan for Future Compliance and how this plan will be implemented. Licensee shall retrain ALL staff that provide Care and Supervision regarding Reporting Requirements and submit signed, dated doc to CCL by POC 12/20/23
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This requirement was not met as evidenced by:LPA learned that the facility was made aware about the incident in late November 2023 and failed to report to the Department of Social Services-Community Care Licensing Division which presents an immediate health, safety and personal rights risk to the residents in care. As well, CCL has not received any reports from facility since 11/21/2023 (4 weeks), when they use to submit SIR’s Hospice Initiations, Death Reports, & SOC’s weekly.
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Plan of Correction for 2nd document due on December 20, 2023.
Type A
12/15/2023
Section Cited
CCR87355(e)(1)

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87355 Criminal Record Clearance- (e) All individuals subject to a criminal record review pursuant to H&S Health and Safety Code Section 1569.17(e) shall prior to...residing...in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by:
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Administrator to ensure all individuals subject to a criminal record review are fingerprint cleared and associated to facility if volunteering or working at facility. Facility to submit a written statement they understand regulation 87355(e)(1) and will be in future compliance.
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Based on LPAs record review and interview with Administrator, facility did not ensure private agency caregiver (I1) was fingerprint cleared and had been working at the facility for approximately three months when incident happened and has been let go. This presents an immediate health and safety risk to residents in care.
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Facility to submit statement to CCL by POC due date 12/15/2023.

Civil Penalties in the amount of $500.00
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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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