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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803891
Report Date: 10/28/2020
Date Signed: 10/29/2020 09:25:15 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200520112433
FACILITY NAME:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:RIDOLFI, ELEINAFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: DATE:
10/28/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Darnell Williams Acting AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff yell at residents
Staff are unable to communicate with residents
Staff do not secure sharp objects
Facility faucets used by residents for personal care do not deliver hot water


INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Darnell Williams this date, for the purpose of delivering findings for the above captioned complaint allegations. The visit was conducted via tele-visit due to the COVID - 19 precautions. During the course of this investigation, this Department has interviewed Complainant and witnesses and obtained and reviewed documents. Based upon those statements and record reviews, the following determinations have been made: Staff state that they have witnessed staff yell at residents; staff report that residents often do not understand staff conversation due to staff speaking in a language other than English; A sharp knife has been observed in the bedroom of R1 by more than one staff person; Staff and other witnesses have reported inadequate or no hot water available for use by residents in the past and state that the problem has been recently corrected. Based upon the LPA's interviews with staff and witnesses, the preponderance of evidence standard has been met. Therefore, the above captioned allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) 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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20200520112433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MARIN TERRACE
FACILITY NUMBER: 216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2020
Section Cited
CCR
87468.1(a)(1)
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87468.1 PERSONAL RIGHTS. Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. Based upon statements made, this requirement has not been met as evidenced
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Administration to provide additional training to all staff on personal rights. Proof of compliance to be provided to CCL by POC date in order to clear the deficiency.
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By: Staff interviewed report that residents often do not understand staff communications due to staff not speaking in English. This posses an immediate violation to the personal rights and safety of residents in care.
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Type A
11/02/2020
Section Cited
CCR
87411(d)(3)
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87411, PERSONNEL REQUIREMENTS. All personnel shall be given on the job training or have ...Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. Based upon statements made, this requirement has not been met as evidenced by:
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Administration to develop a written plan that insures all staff communicate with residents in compliance with the requirements of 87411. Written plan to be submitted to CCL for approval by POC date in order to clear the deficiency.
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Staff interviewed report that residents often do not understand staff communications due to staff not speaking in English. This posses an immediate violation to the personal rights and safety of residents in care.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20200520112433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MARIN TERRACE
FACILITY NUMBER: 216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2020
Section Cited
CCR
87705(f)(1)
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87705 CARE OF PERSONS WITH DEMENTIA. The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).***Based on statements made, this requirement not met as evidenced by:
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Administration to conduct refresher training for all staff in the requirements of 87705. Proof of compliance to be provided to CCL by POC date in order to clear the deficiency.
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Staff report having observed a knife in the room of R1 which could be a accessible to residents in care. This poses an immediate danger to the safety of residents in care.
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Type B
10/28/2020
Section Cited
CCR
87307(d)(1)
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 87307. PERSONAL ACCOMMODATIONS AND SERVICES. The following space and safety provisions shall apply to all facilities:
...(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. *** Based upon statements made, this requirement has not been met as evidenced by:
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Cleared at time of visit. Facility currently has hot water to the bathrooms.
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Staff interviewed state that hot water has not been available in the residents' bathrooms in the recent past. This poses a potential risk to the health of the residents in care.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200520112433

FACILITY NAME:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:RIDOLFI, ELEINAFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: DATE:
10/28/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Darnell Williams Acting AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that residents are adequately fed
Staff do not ensure that resident's toileting needs are met
Facility staff handled resident in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Darnell Williams this date, for the purpose of delivering findings for the above captioned complaint allegations. The visit was conducted via tele-visit due to the COVID - 19 precautions. During the course of this investigation, this Department has interviewed Complainant and witnesses and obtained and reviewed documents. Based upon those statements and record reviews, the following determinations have been made: R2 is difficult to change and clean and resists attempts to provide such care. There are differing opinions as to whether or not staff are rough when changing R2; It is alleged that some residents are not properly or adequately fed; Statements and records reviewed do not confirm the allegation regarding feeding; Facility does not keep record of resident checks for toileting needs and there are differing opinions regarding the sufficiency of the checks which are done by staff. Although the allegations may be true, or are valid, based upon statements and record reviews, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4