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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800977
Report Date: 08/06/2024
Date Signed: 08/06/2024 11:28:21 AM

Substantiated


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
06/20/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240620093300
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 28DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mary McClure, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility allows untrained staff to dispense medications to residents in care
Staff do not ensure facility is kept free of mal odors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegations and met with Mary McClure, Administrator.

Facility allows untrained staff to dispense medications to residents in care – Complainant alleges staff (S1) was hired as a caregiver, received some med tech training and was working as a medtech, then did not pass med tech exam and was relieved of duties on 6/15/2024. S1 was required additional training but did not retake the test and administrator placed S1 back on med tech schedule. LPA obtained training documents for S1 that indicate per Title 22 Regulation has not obtained required hours of initial medication training. Due to LPA’s record review of trainings for S1 regarding Facility allows untrained staff to dispense medications to residents in care, allegation is found to be SUBSTANTIATED.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20240620093300
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: 08/06/2024
NARRATIVE
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Continue from LIC9099-C

Staff do not ensure facility is kept free of mal odors- Complainant alleges due to lack of housekeeping resident’s rooms smell badly as the majority of residents are incontinent and the smell travels through the hallways as you enter the facility. On 7/22/2024 (Monday) LPA toured the facility at aprox 8:54am starting on the 3rd floor and when entering the floor when door opened - there was a pungent smell of urine/mal.
LPA & S2 toured 5 rooms finding 2 bedrooms having strong urine/mal odors which S2 opened windows and removed soiled clothing in laundry basket. LPA was informed from staff interviews there are 2-3 residents who have incontinent issues and behaviors of urinating on the floor in their rooms & in the hallways. Per staff interviews regarding June & July, 2024 the facility does not have housekeeping cleaning on Sunday. Staff schedule obtained supports lack of housekeeping staff on Sunday. The facility just hired a new housekeeper, but staff believe the smell is due to the floors not being cleaned over the weekend. Due to LPA’s observations & interviews regarding Staff do not ensure facility is kept free of mal odors allegation is found to be SUBSTANTIATED.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

The following deficiencies were observed (see LIC 9099D) 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: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240620093300
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
HSC
1569.69(a)(1)
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1569.69(a)(1) Medication Administration Training (a)Each residential care facility for the elderly shall ensure that each employee …who assists residents with the self-administration of medications meets all the following training requirements: (1)In facilities licensed for 16 or more.. employee shall complete 24 hours of initial training…consisting of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction..which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
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Licensee to ensure that all staff obtain the H&S Code initial medication training as required; Submit proof of S1’s, medication training (16 hrs of hands on shadowing training) by POC due date of 8/20/2024.
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Based on: Record review & interview with Administrator, S1 lacks proof of required HSC 1569.69(a)(1) medication training, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
08/20/2024
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence
(b)In addition to Section 87611, General .., the licensee shall be responsible for :(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
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Licensee to ensure an in-service is conducted with all staff regarding incontinent care services to residents. Submit plan of future compliance with this regulation, ensuring staff are checking on resident and changing resident timely...

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Based on statements and observation, this requirement is not met as evidenced by: On 8/22/24 LPA & staff observed 3rd floor of facility and R1 & R2’s rooms having strong incontinence odors. This poses a potential health & safety risk to R1, R2 & other residents in care.
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 & staff are cleaning floors to keep facility free of odors from incontinence.

Submit proof of training. All POC documentation is due 8/20/24.
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: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
06/20/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240620093300

FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 28DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mary McClure, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
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9
Staff do not ensure residents rooms are kept in safe, clean, sanitary conditions
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegations and met with Mary McClure, Administrator.

Staff do not ensure residents rooms are kept in safe, clean, sanitary conditions- Complainant alleges facility does not have sufficient staff to keep up on housekeeping duties. LPA visited facility to open complaint on 6/20/2024 (Thursday at approx. 2:15pm) and observed both 2nd & 3rd floors, hallways, and resident rooms being clean. LPA interviewed Building Services Director (BSD) who informed they are the supervisor for housekeeping staff and for the past 2 months they have been the only housekeeping staff. On 7/22/2024 (Monday) at approximately 8:54am LPA conducted visit of facility and observed 5 rooms on the 3rd floor & 6 rooms on the 2 floor to be clean along with the hallways and dining area. Documents obtained and interviews conducted indicate a new housekeeper was hired on 7/2/2024 & an additional one on 7/21/2024.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240620093300
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: 08/06/2024
NARRATIVE
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 Allegation of Staff do not ensure facility is kept free of mal odors is Substantiated due to odor and lack of housekeeping on sight. Although, LPA was unable to obtain or observed additional evidence to support facility is not safe and sanitary citation issued under reference allegation. Although it was alleged Staff do not ensure residents rooms are kept in safe, clean, sanitary condition 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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5