216800977-5-15-2023-21-AS-SHAN-CRUNUZ-20230515104709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 05/15/2023
Date Signed: 05/15/2023 10:47:18 AM

Document Has Been Signed on 05/15/2023 10:47 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:	05/15/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Kari Oxford, Administrator		TIME COMPLETED:	10:55 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

License Program Analyst (LPA) Shannan Hansen arrived at 8:45 AM to complete an unannounced annual inspection and met with Kari Oxford, Administrator. There is a total of 29 memory care residents.

LPA continued file review of five personnel files and it was revealed that 3 (S1, S2, & S3) of the 5 staff that are required to have First Aid certification per Title 22 Regulation 87411(c )(1) did not, (see LIC 809-D) and 2 of the 5 staff (S2 & S3) sampled for review were not associated to the facility as required by Title 22 regulations 87355( e)(2) (see LIC 809-D).

LPA reviewed centrally stored medication record and conducted staff interviews to complete this annual inspection.

During inspection LPA followed up on elopement that was self reported to community care licensing (CCL) on 5/12/2023 that on 5/11/2023 at approximately 1:10 am resident (R1) had eloped from community. Facility staff and law enforcement conducted search and located R1. Law enforcement returned R1 to community approximately 1 hour later. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave unassisted. LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 5/11/2023. Facility has let staff go and increased staffing floor number, fixed electrical system caused by city power outage, conducted in service training on elopement, and has increased status checks.

Continued on LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: 05/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Hansen is requesting Licensee to update and submit the following documents by 6/05/2023 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

Control of Property

Copy of Administrator Certificate

Proof of Liability Insurance

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 05/15/2023 10:47 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review conducted on May 15, 2023, the Administrator did not comply with the section cited above in 3 out of 5 staff members who are required, did not have current First Aid as required by Title 22 regulations. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Administrator to ensure that all required staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1, S2, & S3 to CCL by POC date of EOB 5/18/2023.

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance- (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, today's visit and verification with CCL: Licensee did not ensure the regulation above due to S2 & S3 who were fingerprint cleared but NOT associated to this facility as required. This is an immediate risk to the Health & Safety of residents in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to associate S2 & S3 to facility. Facility to submit a written statement they understand regulation 87355(e)(2) and will be in future compliance. Facility to submit statement to CCL by POC due date 5/18/2023.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/15/2023 10:47 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(b)(2)

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on a review records and interview with RCC it was found that resident (R1) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	Facility provided in-service training conducted, for regulation 87705 Care of Persons with Dementia with staff. But has not submitted LIC9098 with date & signatures of staff, to be submitted by 5/17/2023. Facility has also fixed electrical issue, and increased status checks.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4