216800977-5-15-2023-21-AS-SHAN-CRUM25-20230515091256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 05/12/2023
Date Signed: 05/15/2023 09:13:07 AM

Document Has Been Signed on 05/15/2023 09:13 AM - 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 MARIN		FACILITY NUMBER:	216800977
ADMINISTRATOR:	KARI OXFORD		FACILITY TYPE:	740
ADDRESS:	1111 SIR FRANCIS DRAKE RD		TELEPHONE:	(415) 482-4100
CITY:	KENTFIELD	STATE: CA	ZIP CODE:	94904
CAPACITY:	55	CENSUS: 29	DATE:	05/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Gary Forer, Director of Sales & Marketing and Ashley Perrone, Resident Care Director		TIME COMPLETED:	03:45 PM

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License Program Analyst (LPA) Shannan Hansen arrived at 8:30 AM to conduct an unannounced annual inspection and was greeted by Gary Forer, Director of Sales & Marketing. Resident Care Director (RCD) Ashley Perrone arrived shortly after. Administrator was unable to attend inspection so the Resident Care Director signed report. There is a total of 29 dementia residents and 7 residents under Hospice care.

Facility tour/inspection began at 9:00 AM:

Beginning at approximately 9:33 AM, LPA toured the community with Building Services Director (BSD) Jason James. The tour of the facility included nine resident apartments, activity rooms, Salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstructions. Delayed egress doors have audible alarms when doors are opened without access codes. Hot water temperature measured within regulation of 105 to 120 degrees F in nine of nine rooms tested. Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchenettes were inspected and maintained per regulation. Menus with snack and beverages are available to residents. Activity schedules are posted. Facility has multiple indoor and outdoor sitting areas and a private dining area.

Continued on LIC809C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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: 05/12/2023

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Continued from LIC809

Fire extinguishers were last serviced 11/7/2022. Fire safety system including smoke detectors and carbon monoxide detectors are checked quarterly by facility staff and are on a regular service schedule with a vendor, last inspected 5/10/2023.

LPA initiated a file review of five resident files and five personnel files but were unable to complete. LPA was also unable to review medication, and conduct remaining interviews and will return at a later date to complete annual inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

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