216803891-11-20-2023-21-AS-BMOS-CXTR5L-20231122114321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803891
Report Date: 11/20/2023
Date Signed: 11/20/2023 12:34:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2023 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230918101730

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: 25	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Erlinda Ferris (acting Administrator)		TIME COMPLETED:	12:49 PM

ALLEGATION(S):

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-Staff did not provide proper assistance to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with acting Administrator Erlinda Ferris.

There is an allegation that staff did not provide proper assistance to residents in care. Per reporting party, resident (R1) often becomes physically aggressive with staff resulting in staff not been able to assist with showering in the past two months. Based on LPA’s interview conducted with acting Administrator, R1 has a behavior and will be assisted with bathing “only once a month, R1 does not get a sponge bath, does not get a change of clothes for days or weeks and will attempt to leave the facility, due to their agitated behavior will run after caregivers that attempts to provide care, which is interpreted as refusal of services by the facility staff.” Per acting Administrator, a times R1 may be given a PRN due to aggressive behaviors. However, R1 is uncooperative in taking their medications, so it has been a huge challenge to provide care for R1.
Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230918101730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/20/2023

NARRATIVE

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Continued from LIC9099...

On 9/19/23 LPA conducted confidential interviews with staff that confirmed staff have not been assisting R1 with regular daily living activities due to R1’s aggressive behavior that they make them feel afraid of resident, so they leave them alone. Based on records review, facility provided LPA with a copy of R1’s daily progress notes for the months of August and September 2023, it was revealed that on 8/1/23 resident was assisted with dinner only, 8/3/23 R1 refused three times to take a shower when offered by staff, (8/15/23, 8/25/23 and 9/14/23) R1 was aggressive with staff, then on 9/15/23 R1 had to be transported to the Hospital due to their aggressiveness and difficulty of staff to care for them. LPA was provided with an incident report confirming the situation where responsible parties were notified. LPA obtained outside agencies reports, which confirmed through interviews conducted with staff that R1 has not bathed in two to three weeks due to their behavior. On 10/3/23, co-complainant added to the same allegation reporting that facility staff identified the reason for not providing care to R1, to be their behaviors. Additionally reported a decrease in food intake, which may be due to R1’s refusal to eat or lack of food being provided to R1 by facility. However, based on records review of R1’s hospital records, there was a concern about intake refusal to eat, but weight data taken on 9/15/23 revealed that R1 has gained weight increasing to 151 pounds from last encounter on 5/29/23 reading of 143 pounds. LPA reviewed R1’s physician report and care plan that indicates facility will assist R1 with showers at least twice per week. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. 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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230918101730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/21/2023 Section Cited CCR 1569.269(a)(6)	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	Administrator agrees to submit a plan to ensure facility is following up on resident’s care needs to CCL by POC due date.
	8 9 10 11 12 13 14	Based on LPA’s records review and interviews conducted with staff, the Administrator did not ensure that resident (R1) was assisted with proper care while residing in the facility, which poses an immediate risk to the health & safety of resident in care.	8 9 10 11 12 13 14
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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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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