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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803891
Report Date: 03/04/2024
Date Signed: 03/04/2024 11:33:14 AM


Document Has Been Signed on 03/04/2024 11:33 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:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:THOMAS EISEMANFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: 29DATE:
03/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Nickolas Thompson (lead med-technician)TIME COMPLETED:
11:48 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with Nickolas Thompson, lead med-technician. Administrator Erlinda Ferris was off for the day, but she was available by phone and gave authorization for staff to sign the report.

LPA learned through records review and interviews with Administrator had failed to provide incident reports to CCL and resident's (R1) responsible parties including hospice about R1's incidents of falls. Per hospice records, on 11/17/23 at 2:18pm, they were notified by an outside party that R1 was found lying on the floor and staff told them that this “has been happening a lot”. However, the facility did not notify responsible parties about it. According to hospice documents obtained indicates that on 11/22/23 hospice had a discussion with the administrator to ensure communications of R1’s condition to ensure timely hospice and medical care was provided. The Department will be scheduling a meeting to discuss areas of concerns and non-compliance for complaint # 21-AS-20231128151806.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Administrator over the phone and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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Document Has Been Signed on 03/04/2024 11:33 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: MARIN TERRACE
FACILITY NUMBER: 216803891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/25/2024
Section Cited
CCR
87211(a)(1)(B)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by:
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Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, contact an outside vendor to conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed & sign in sheet for all staff trained to be submitted by POC due date.
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Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1 after falls. Per hospice records revealed that R1 had incidents of falls and changes of conditions that were not reported to them nor CCL, which poses a potential health & safety risk to residents in care.
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Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
LIC809 (FAS) - (06/04)
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