216803891-4-4-2023-21-AS-MCUA-CQKT23-20230404142005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803891
Report Date: 04/04/2023
Date Signed: 04/04/2023 02:21:20 PM

Document Has Been Signed on 04/04/2023 02:21 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:	MARIN TERRACE		FACILITY NUMBER:	216803891
ADMINISTRATOR:	THOMAS EISEMAN		FACILITY TYPE:	740
ADDRESS:	297 MILLER AVE		TELEPHONE:	(415) 388-9526
CITY:	MILL VALLEY	STATE: CA	ZIP CODE:	94941
CAPACITY:	49	CENSUS: 16	DATE:	04/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Erlinda Ferris (acting Administrator)		TIME COMPLETED:	02:35 PM

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	Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with acting Administrator, Erlinda Ferris. There are residents receiving hospice services. Upon arrival, LPA observed that staff continue to wear masks per current guidance. LPA initiated a tour of the facility around 9:00am and made the following observations: facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closets. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked in medication rooms. Facility has hardwired combination Smoke/Carbon Monoxide detectors located throughout the facility that are maintained by a vendor and recent service was conducted November 2022. Medications and medication records were reviewed. Facility stairwells in the building have the required evacuation chair. Administrator Certificate for Administrator Erlinda Ferris 6054488740 expired 12/8/2021. Per Erlinda, their renewal paperwork has been sent in and have proof that paperwork was submitted to Community Care Licensing (CCL). At approximate 9:10am LPA/Administrator observed water temperature in various sinks accessible to residents in care measured at 126.5, 118.6, 109.9, 120.1, 127.2 and 129.4 degrees F which are not within the range of 105 to 120 degrees F allowed per regulation. Fire extinguishers were last serviced January 2022. Fire/disaster drill has not been conducted within the last quarter as stated per regulation. Six staff files and five resident files were reviewed. Four out of six staff does not have current required First Aid, CPR certificates and annual required training hours. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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: MARIN TERRACE	FACILITY NUMBER: 216803891
	VISIT DATE: 04/04/2023

NARRATIVE

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Continue from LIC809...

During today's interviews with staff it was brought up that the facility is in the process of creating an assignment sheet based on resident's daily care needs as a communication tool between staff. Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Administrator agreed to submit updates of the following documents by 4/21/2023: Liability Insurance, LIC308 Designation of facility responsibility, lease agreement, Administrator documentation needed LIC 215 Applicant Information, First Aid Certificate, Administrator Resume, LIC 500 Personnel Report, LIC 501 Personnel Record, Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations).

Deficiencies 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. Appeal rights given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2023 02:21 PM - 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: MARIN TERRACE	FACILITY NUMBER: 216803891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the facility did not comply with the section cited above in 5 out of 5 fire extinguishers had not been serviced since January 2022 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2023
	Plan of Correction
1 2 3 4	Administrator contacted the Fire Department to have fire extinguisher serviced. Administrator agreed to submit self-certification form as a proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date.

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the facility did not comply with the section cited above in 4 out of 6 faucets used by residents in care have 126.5, 120.1, 127.2 and 129.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2023
	Plan of Correction
1 2 3 4	Administrator will adjust water temperature and agreed to submit self-certification form as a proof of Correction (POC) that water temperature is within regulation by POC due date.

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) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2023 02:21 PM - 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: MARIN TERRACE	FACILITY NUMBER: 216803891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 6 staff have CPR training on the premises which poses a potential health, safety risk to residents in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to ensure that at least one staff on duty has CPR training at all times. Licensee to submit LIC 9098 self certification that at least one staff has been certified for CPR per regulation and that facility will maintain a staff on duty who has CPR training at all times. Self certification to be submitted by POC due date.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record observation, interviews and records review 6 out of 6 staff did not have the required annual 20 hours training which poses a potential health, safety, personal risk to residents in care.
	POC Due Date: 05/01/2023
	Plan of Correction
1 2 3 4	Administrator agrees to have staff complete training and send to CCL with form LIC9098 by POC due date to clear deficiency.

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) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2023 02:21 PM - 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: MARIN TERRACE	FACILITY NUMBER: 216803891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review and interview, the facility failed to conduct an emergency drill within the past quarter. This poses a potential health and safety risk to residents in care.
	POC Due Date: 05/01/2023
	Plan of Correction
1 2 3 4	Administrator agrees to conduct and document disaster drills every 3 months on all shifts with all direct care staff. Licensee agrees to conduct a disaster drill on all shifts with all direct care staff and submit proof to CCL by POC due date.

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) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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