216800977-1-11-2024-21-AS-VBEI-CZERMZ-20240112120932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800977
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:05:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/26/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20231226140340

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: 29	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Kari Oxford, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff does not ensure residents allowed to leave their rooms at the facility
Licensee does not ensure that staff are able to communicate with residents in care
Staff do not ensure care needs are being met for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Kari Oxford.

Staff does not ensure residents allowed to leave their rooms at the facility – Complaint alleges facility locks all of the residents in their rooms. Per Interview with staff (S1), residents’ doors are locked as a safety precaution due to memory issues, so that other residents don’t come into other resident’s room and take things or think it is their room. S1 also indicated residents are only locked on the outside, but if residents are inside of a locked door they can get out. On 12/28/2023 while touring third floor of facility, LPA found an unlocked room, locked the door prior to closing on the inside handle, tested the outside handle that did not move and shut the door. LPA was able to open the locked door from the inside by pushing the handle down. Follow up call with reporting party informed they do not have additional evidence or information to provide. Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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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Control Number 21-AS-20231226140340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/11/2024

NARRATIVE

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Although it was alleged that residents are unable to leave their rooms, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Licensee does not ensure that staff are able to communicate with residents in care – Reporting party (RP) alleges many staff who work at facility do not speak or understand English and therefore cannot communicate with residents. Reporting party could not give specific name of staff or residents who allegations were referring to. On 12/28/2023 while opening complaint, LPA went to both second and third floors where residents reside of this full dementia facility and spoke with 2 housekeepers, 3 medication technicians, 2 caregivers, and the activities director. LPA observed exercise activities being conducted and residents talking with and being directed by activities director. LPA also observed the other 5 staff speaking with residents without any communication problems other than possible dementia issues. Also, while LPA was conducting interview with R1, S2 was delivering their meal and was requested by R1 of S2 to give LPA a message, which S2 did. Although it was alleged that the licensee does not ensure that staff are able to communicate with residents in care may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Staff do not ensure care needs are being met for residents – Complaint alleges residents care needs are not being met as they are not being checked on per resident (R1) to reporting party. Reporting party also indicated R1 does not have a diagnosis of dementia. Conflicting to reporting parties’ statement, LPA’s file review revealed, the residents (R1) physician report (602) dated 9/2023 shows a diagnosis of dementia. Progress notes of 12/23/2023 to 12/25/2023 do not indicate due to care needs not being met, there was negative effects. End of Shift reports for same time period show residents slept all night and no issues or concerns during checks. LPA’s interview with S1 on 12/28/23 revealed bed checks are conducted every 2 hours and there is a log sheet that staff will notate in when they do something for the resident or if the residents are not eating or need a shower, have a bowel movement, etc. LPA conducted interview with S3 on 1/2/2024, that corroborated with S1, stating that if the resident doesn’t need help they do not write anything on the report. S3 was on shift during stated time period and end of shift report is notated as, residents slept all night and no issues or concerns during checks. LPA also obtained call logs from facility for time period in question that revealed only 1 resident requested attention, that was not R1. Therefore, the allegation, staff do not ensure care needs are being met for residents is Unsubstantiated.

Based on LPAs observations, record reviews, interviews with staff, resident, and conflicting information obtained from party’s, there is insufficient information to prove or disprove the allegations listed above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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