<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803891
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:08:37 PM


Document Has Been Signed on 04/11/2024 02:08 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 TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:THOMAS EISEMANFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: 0DATE:
04/11/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Erlinda Ferris (acting Administrator)TIME COMPLETED:
12:00 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
An informal meeting was conducted today via Microsoft Teams. Present in the virtual meeting were Licensing Program Manager Bethany Moellers, Licensing Program Manager Victoria Bertozzi, Licensing Program Analyst Helena Rummonds, Licensing Program Analyst Marisol Cuadra, Licensee Dinesh Sawhney, acting Administrator, Erlinda Ferris, other attendees Rico Foz, Meryl Foz and Payam Saljoughian.

The purpose of the informal office meeting was to discuss areas of non-compliance and observed and ongoing Community Care Licensing concerns of the operation of Marin Terrace #216803891. The Attendees were informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. The legal administrative action process was explained to attendees which is based on substantiated complaint findings found on complaint investigation.

Items addressed in today's meeting include but are not limited to patterns and trends in the areas below:
  • Personal Rights including resident ADLs not provided as assessed in their care plans.
  • Timely seek for medical care by assisting residents in a timely manner.
  • Reporting Requirements of incidents occurred at the facility were not notified to CCL
  • Personnel Requirements including lack of staffing to meet resident’s care needs.
  • Basic Services include providing residents with a menu that meets the recommended dietary allowances of the Food and Nutrition Board of the National Research Council.
  • Acting administrator and involvement in the facility operation.
Continued on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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 2


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: 04/11/2024
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
Continued from LIC809...

Documents requested during informal meeting to be submitted to CCL by 04/19/2024:

· Updated Personnel Report (LIC 500) including staff assigned to provide assistance to residents located in the back building.
· Administration Organization (LIC309)
· Licensee to ensure the facility has a current Administrator or submits required documentation to change in Administrator: LIC215, LIC500, LIC501, current Administrator certificate and detailed employment/education history.
· Licensee to develop policy identifying staff member responsible for ensuring all deficiencies are addressed, special incident report is submitted to designated agencies.

Failure to submit the above documentation may result in the Department seeking further action. The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint # 21-AS-20231128151806.

No deficiencies cited during today’s informal virtual conference visit. Copy of this report will be emailed to obtain signatures.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2