216800977-6-30-2022-21-AS-BMOS-CGAMDU-20220713093140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800977
Report Date: 06/30/2022
Date Signed: 06/30/2022 09:57:39 AM

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
03/07/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20220307121551

FACILITY NAME:	WINDCHIME OF MARIN		FACILITY NUMBER:	216800977
ADMINISTRATOR:	BRITTANY KARLINSKI		FACILITY TYPE:	740
ADDRESS:	1111 SIR FRANCIS DRAKE RD		TELEPHONE:	(415) 482-4100
CITY:	KENTFIELD	STATE: CA	ZIP CODE:	94904
CAPACITY:	55	CENSUS: 78	DATE:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Interim Administrator Deborah Savoie & Tony Ibarra Jr. Business Office Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen made an unannounced subsequent visit to the facility. The purpose of this visit is to deliver findings for the above allegation. LPA met with Interim Administrator Deborah Savoie and Business Office Director Tony Ibarra Jr.

Complaint alleges resident sustained an unexplained injury while in care. During the investigation LPA reviewed records, made observations at the facility and conducted interviews. Records indicate resident (R1) was admitted to facility at the end of 9/2021 with diagnosis of dementia. Incident report to Community Care Licensing indicated on 11/19/21 R1 was found laying on the floor by their bed closest to the wall with bleeding to the left side of head. R1 was taken to hospital and discharged same day to POA with no new orders. Interview with Executive Director Ibarra, POA took R1 to POA’s home and returned to facility 9 days later. On 12/6/2021 POA initiated a one on one caregiver for R1 from 10 pm to 6am 7 days a week. Records indicate at the end of December 2021 R1 was admitted to Hospice, due to Lewy Body dementia, progressive failure to thrive.
Continue on 9099-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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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-20220307121551

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: 06/30/2022

NARRATIVE

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Record review and interview with the care director revealed the 1:1 caregiver called out sick on 3/4/21 and also informed on 3/4/21 that R1 had a fall on 3/3/21 due to tripping over R1’s walker. Based on care plan obtained R1 is a fall risk. Care notes for 3/4/21 indicate that R1 was not showing any signs of discomfort. On 3/5/21 care notes indicate R1 was restless at 1am and observed coming out of room multiple times, re-directed back to bed and PRN given. R1 reported having leg pains while sitting up at 8:30am on 3/5/21, med-tech administered PRN at 8:37am (no effect) and called hospice to inform. At approximately 10 am resident complaining of increased pain but not due for PRN. Faciltiy notified POA R1 would be sent out to ER due to pain, identified. POA arrived to facility and took R1 to own home and later called hospital and patient was transported to ER. Complaint also indicates R1 sustained a fractured right hip. R1 never returned and was discharged from facility. R1 passed away on 3/13/2022, death certificate was obtained and no indication of hip fraction. LPA obtained medical records from 3/5/21 hospitalization which indicates right hip fracture. Based on LPAs investigation R1s injury was not unexplained and mostly likely caused from a fall.

Although the allegations above 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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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