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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:11:25 PM


Document Has Been Signed on 10/06/2022 12:11 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:KARI OXFORDFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 31DATE:
10/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Kari Oxford Administrator & Ashley Perrone Resident Care DirectorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Kari Oxford, Administrator. The purpose of this case management inspection is to follow up on an SOC341 & two self reported incident reports submitted to Community Care Licensing (CCL) 10/3/2022.

CCL received two self reported incident report and an SOC 341 form on 10/3/2022 reporting on 9/2/2022 staff S1 had reported to have witnessed at at approximately 7:15am R2 had gotten up and was going out with caregiver but needed to use the bathroom first. R1 was outside of R2's room. Shortly after another caregiver witnessed R1 punch R2 in the face and R1 had blood on hands and walked away out of R2's room as if nothing had happened. R2 was taken to hospital for evaluation & treatment for swollen and bruising on face & returned to facility same day.

Incident 2 occurred on 9/28/22 at approximately 7am R1 tried punching 1 on 1 care staff. Med tech was helping on floor and observed R1 following another resident and getting agitated at 1 on 1 again and R2. 911 was called due to residents aggressive behavior R1 was transported to hospital for evaluation.


Resident was separated and re-directed by staff POA, PCP, and law enforcement informed & called.
All appropriate parties were contacted. Facility is working with PCP and responsible party.


On 10/6/22 at 10:30 AM LPA Hansen spoke with RCD Ashley Perrone. RCD informed that on 9/27/22 the facility had a meeting wtih R1's PCP regarding the issues and to advocate medications. Resident is still at hospital.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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