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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:52:04 PM

Document Has Been Signed on 01/07/2025 03:52 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR/
DIRECTOR:
MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 55CENSUS: 27DATE:
01/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lauren Cottman- Executive Director TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 1/7/2025 at 2:00pm, Licensing Program Analysts (LPAs) Frank and Felias arrived unannounced to conduct a Case Management inspection and met with Executive Director, Lauren Cottman and Resident Care Director, Parinda Kleinberg. The facility submitted an Incident Report (IR) for Resident 1 (R1) for a medication error.

The IR stated that on Sunday 12/8/2024 Resident Care Director reviewed medications orders and found new orders from the resident's doctor. The new orders received stated that facility was to stop one medication and start a new medication once it was received by the facility. The med tech on duty (S1) faxed orders to the pharmacy the same day but gave both medications to the resident on the 12/6/24 and 12/7/24 PM shifts. Resident Care Director faxed details of the incident to R1's primary physician and notified the resident's responsible party.

LPAs reviewed documentation. Correspondence between facility and R1's primary care physician showed that R1's new medication was not sent by the pharmacy until 12/6/24. Facility received the new medication on 12/8/24. R1's Medication Administration Records (MAR) shows that R1's old medication was given on 12/6/24, 12/7/24, and the morning of 12/8/24. R1's new medication arrived the evening of 12/8/24. Review of R1's MAR showed that when the new medication arrived to the facility, the old medication was discontinued and the new medication was administered appropriately. Review of records showed that there was no overlap in medications.

No deficiencies cited.

Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of document.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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