216800977-7-28-2022-21-AS-BMOS-CHCTGC-20220816144256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800977
Report Date: 07/28/2022
Date Signed: 07/28/2022 10:27:00 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
06/27/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20220627103333

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: 32	DATE:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Executive Director Kari Oxford, and Business Office Director Tony Ibarra Jr.		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident's records are not being provided when requested by authorized representative.

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 Executive Director Kari Oxford, and Business Office Director Tony Ibarra Jr..

Complaint alleges resident’s records were not being provided when requested by authorized representative. During the investigation LPA reviewed records, made observations at the facility and conducted interviews. Complaint alleges first request was submitted on 4/5/2022 and second was sent on 4/7/2022 and then sent via fax on 4/21/22. On 5/4/2022 request was left via voicemail. Interview with Business Office Director (BOD)Tony Ibarra on 6/30/22 informs the first request to his knowledge was May 2022 a voice mail from (T1) at T-Scan requesting residents (R1) full medical records, although BOD could not send until receiving request form from T-Scan signed by a POA (HIPPA) and had not received that via email or fax. BOD initially spoke with T-Scan representative T1 on 6/15/2022 and explained needing the signed legal document form.

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: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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-20220627103333

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: 07/28/2022

NARRATIVE

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The investigation revealed requestor was sending request to medication room. Once BOD obtained copy of signed legal document then obtained copy of all medical records to send to requestor. Documents compiled approximately half a ream of paper. BOD proceeded to get help from staff to send documents via email to requestor. Staff was unable to find T1 on any email to return documents and called T-Scan and spoke with T2 who informed to send to her email. On 6/15/2022 documents were sent in 3 different parts to minimize the size. Unbeknownst to staff the email was returned as decline/undelivered email. BOA tried sending to email address in different forms but still undeliverable. On 6/29/2022 BOA called T2 and could only leave a voicemail with issue of request. On 6/30/2022 BOA spoke with T3 at T-Scan who informed if a large document size is being sent it would be undelivered. BOA requested to send overnight via fed ex and requestor agreed. LPA’s investigation revealed facility was not intentionally withholding records and delay was due to lapse of communication. BOA provided records when T-Scan provided clear means to provide the records.

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: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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