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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 05/26/2022
Date Signed: 05/26/2022 02:19:20 PM


Document Has Been Signed on 05/26/2022 02:19 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:BRITTANY KARLINSKIFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 33DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tony Ibarra Jr. Business Office Director & Loata Taole Resident Care Director TIME COMPLETED:
02:19 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by front desk staff who directed LPA to sanitize hands, screen for symptoms, and sign-in on the visitor sheet. Front desk contacted Resident Care Director Loata Taole for the visit. There are 33 residents in care at the facility with 7 on Hospice.

At approximately 9:45 am on 5/26/2022, Interim Executive Director, Tony Ibarra arrived at the facility and began the inspection. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/4/2021 at the time of the visit. Fire sprinkler system (Matrix) which is connected with smoke and carbon monoxide detectors was last inspected on 1/18/2022. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in the laundry room cabinet on the first floor. However, Lysol was found in an unlocked cabinet on the second floor kitchenette accessible to residents, along with nail polish remover in R1’s night stand (see pictures, LIC 809-D), which were removed by Administrator during inspection. Dangerous items are kept in the main kitchen or locked in the medication room. However, R2 had a box of razors, nail clippers, and scissors in his bathroom (see pictures, LIC 809-D). All resident’s bedrooms have lighting & appropriate furnishings. In 7 out of 9 residents bathroom faucets hot water temperature measured between 121.8 degrees F and 124.5 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees (see LIC 809-D). Administrator contacted facility service vendor during tour to adjust the water temperature today. Residents’ medications are centrally stored and locked in the medication room on the second floor. Facility has a 30-day supply of medication for residents.

Continue on LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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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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
VISIT DATE: 05/26/2022
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Infection Control:
Facility has submitted a mitigation program plan that was approved on 6/15/2021. Posters have been placed at entrance, and facility has a station at main entrance with electronic temperature reader, sign in sheet, and hand sanitizer designated for visitors and staff.

Facility has PPE supply stored on the second-floor locked supply closet. All staff had masks on during this visit. Residents have also available Facetime, Zoom, and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and acquired N-95 fit testing.



LPA reviewed Licensing Information System (LIS) with Interim Administrator who stated that is all correct and up today at this time. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one conducted on 3/31/2022, the last fire drills 3/31/2022.

LPA was presented with proof of current CPR & 1st Aid certification for staff.


Administrator Certificate is for Brittany Karlinski # 6048414740 Exp. 6/17/2022
All staff have received COVID booster vaccinations.

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.

Appeal of Rights Given

LPA Hansen is requesting Licensee to update and submit the following documents by 6/15/2022 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/26/2022 02:19 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: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2022
Section Cited

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87705 (f)(2) Care of Persons with Dementia. (f)The following shall be stored inaccessible to residents with dementia: (2)Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Based on LPAs observation and interview the facility failed to ensure toxins are stored inaccessible to residents in care which poses an immediate health and safety risk to residents in care.
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In addition, Administrator to conduct an in-service training and will submit proof of training to include regulation discussed, attendees signature and date/time of training. Submit roster to CCL by 6/07/2022.
Type A
05/27/2022
Section Cited

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87705(f)(1)Care of Persons w/Dementia - The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: *** Based on observation the licensee failed to maintain sharp objects /scissors
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locked in the facility resident bedroom which poses an immediately Safety risk to residents in care. LPA toured the facility & observed a box of razzors, nail clippers, and an unlocked pair of scissors in resident's R2 bathroom.
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danger to the resident's in care. Facility to submit a LIC 9098 self certification that all items that constitute danger has been removed, and that caregivers & housekeepers are aware of this regulation by POC date of 5/27/2022.
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: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/26/2022 02:19 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: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2022
Section Cited

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This requirement is not met as evidenced by: 87303(e)(2) Maintenance & Operation.Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F. This requirement is not met as evidenced by:
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Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 7 of 9 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA toured the facility w/ Interim adm. and observed that 7 of the 9 hot water temperature ranged between 121.8 and 124.5 degrees F.
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 Facility to begin monitoring for the next 7 days. Interim Admin to submit a 7 day log taken from the resident's bathrooms to CCL by 6/07/2022.

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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: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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