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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803891
Report Date: 03/04/2024
Date Signed: 03/04/2024 11:40:27 AM

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
11/28/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231128151806
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
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Nickolas Thompson (lead med-technician)TIME COMPLETED:
11:55 AM
ALLEGATION(S):
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-staff did not provide adequate supervision to resident in care.
-Staff failed to seek timely medical care for residents.
-Staff did not assist a resident with showering and toileting.
-Staff violated residents’ rights.
-Staff did not ensure resident was provided proper nutrition.

INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations 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.

There is an allegation staff did not provide adequate supervision to resident in care. Per the reporting party, R1 was left with part of their body outside of the bed for an unknown amount of time. On 11/21/23, it was decided to hire a full-time one-on-one caregiver due to concerns about care and supervision not being provided to R1. Based on records review, on 10/17/23 R1’s physician ordered R1 to receive hospice services due to concerns about rapid decline of R1’s health, fall risk, care and supervision concerns. Also, the physician ordered the facility staff to assist with bathing, toileting, continence, dressing, transfers, assisted daily living activities (ADLs) as well as inspect R1’s skin by repositioning them every two-three hour to prevent them from pressure injuries ensuring that call light is located within reach to R1. Continue on LIC9099C...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 21-AS-20231128151806
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: 03/04/2024
NARRATIVE
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Continued from LIC9099...

On 11/21/24 the outside party reported that there were no facility staff coming to perform prescribed reposition checks on R1 every two-three hour as prescribed by their physician. LPA obtained a picture of R1 found sleeping on the floor. The administrator confirmed that facility staff were not assisting R1 that night and ensured that it did not happen again. Per Administrator, the facility implemented a communication log for staff to document their checks. LPA was provided with logs between 10/17/23 to 11/22/23 where on different dates (10/24/23, 10/26/23,10/28/23, 10/31/23 and 11/2/23), staff reported that R1 was knocking on the back door of main building trying to come inside the facility. Based on interviews conducted with facility staff, it was revealed that night shift staff will lock the back door of the main building of the facility to block R1 from coming into the facility, and not checking on them to ensure that any possible care needs were met. 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.

Regarding the allegation of staff failed to seek timely medical care for residents. Per Reporting party, on 11/2/23 Administrator notified R1’s responsible parties that R1 was out of control, reporting property damage to the flower garden and sink, but not reporting any injuries. However, based on records review of skin integrity monitoring form on 11/4/23 R1 was found around 3pm by staff with a big bruise on their right leg. On 11/7/23 at 10:40am hospice records confirmed that facility did not report any falls to them, but R1 was observed by hospice nurse with significant bruising. On 11/13/23 hospice records confirmed that the facility administrator notified them about R1’s aggressive behavior and destruction of property. 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. On 11/20/23 the hospice agency scheduled R1 for x-rays to be done where results were negative for any fractures. On 11/21/23, R1 was found unconscious with a dropped jaw and staff disclosed to an outside agency that R1 sustained the injuries and decline in health because a sink fell on them weeks earlier. The reporting party expressed that it seemed like an unknown staff found R1 injured and physically moved R1 to their bed without assessing or attempting to seek medical treatment for R1. Staff tried aggressively shaking and yelling at R1 to wake them up and feed them without notifying hospice about the incident. 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. Therefore, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Continues on LIC9099C...

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
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 21-AS-20231128151806
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: 03/04/2024
NARRATIVE
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Continued from LIC9099C...

The administrator could not provide proof that incidents were reported to CCL nor responsible parties. LPA will address reporting requirements on a case management inspection. 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.

Another allegation of staff did not assist a resident with showering and toileting. On 11/18/23, R1 started receiving services from a private caregiver who was hired part-time to provide companion to R1 due to safety concerns. Per the reporting party, staff did not want to change or bathe R1 and wanted the private sitters or the responsible parties to do it supposedly due to their aggressive behavior. Based on records review, this allegation had been previously investigated and determined Substantiated under complaint# 21-AS-20230918101730. However, on 10/14/23 R1 came back to the facility and staff still did not assist R1 with shower and toileting. Based on interviews conducted with the Administrator, LPA confirmed that R1 returned from hospital with no aggressive behaviors due to medication adjustments made by their physician. On 11/18/23, private caregiver reported that facility staff did not come to check on R1 until 4am. Based on hospice records confirmed concerns with showering and toileting needs been met for R1. 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.

Last allegation about staff violated residents’ rights. Per reporting party, on 11/17/23 they arrived unannounced to the facility to visit R1, but two staff started running to the back building where R1 was residing, so outside party did run as well behind them and found R1 unattended on the floor wearing only pull-up diaper. LPA obtained a picture showing R1 laying on the floor with a staff standing next to them. Based on interviews conducted with outside party, who confirm to LPA the incident, they were told by staff that they were checking on R1 every two hours, and they ensured that they were just there checking on them five minutes ago. However, outside party touched the bedsheets that were cold, then they requested staff to help them to have R1 transferred to bed, but staff replied that they will have to wait until med-technician or someone else who’s job it was to assist R1 with transferring to their bed. 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. Continues on LIC9099C...

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
LIC9099 (FAS) - (06/04)
Page: 3 of 9
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
11/28/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231128151806

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
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Nickolas Thompson (lead med-technician)TIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
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-staff did not allow residents to have visitors.
-resident sustained multiple unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations 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.

The Department received an allegation of staff did not allow residents to have visitors. Per Reporting party, after resident (R1) came back from the hospital, staff decided when R1 could receive visitors, on 10/16/23 there was an incident when an outside person (I1) wanted to visit R1 but was told by staff (S1) to not come by that day until “Thursday at noon” to supposedly give R1 time to settle in from the hospital. The reporting party expressed concerns about limits on visitation. Based on records review, the facility log indicated that R1 received visitors on different dates (10/14/23, 10/16/23, 10/24/23, 11/20/23 and 11/22/23). However, there was conflicting information around whether R1 could receive visits or not. Based on interviews conducted with facility staff, they were allowing R1 to have visitors in compliance with their visiting hours policy.
Continue on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 21-AS-20231128151806
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: 03/04/2024
NARRATIVE
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Continues from LIC9099A...

A finding that the complaint allegation occurs of staff did not allow residents to have visitors is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation of resident sustained multiple unexplained injuries while in care. Per reporting party, resident (R1) sustained unexplained injuries causing soreness and discoloration to their extremities. Reporting Party reports the resident was found sleeping on the floor. Based on records review, the reporting party alleges R1 was receiving hospice services on an average of two-three visits per week for symptom management. On 11/2/23 Administrator notified R1’s responsible parties that R1 was out of control, reporting property damage to the flower garden and sink, but not reporting any injuries. Based on LPA’s records review of skin integrity monitoring form on 11/4/23 R1 was found around 3pm by staff with a big bruise on their right leg. However, hospice records revealed that they conducted a visit to R1 on 11/6/23 at 1:24pm and the facility did not report anything to them. On 11/7/23 at 10:40am hospice records revealed that facility did not report any falls, but R1 was observed by hospice nurse with significant bruising on right hip with worsening bruising on right upper/inner/posterior thigh, bruise to left temple. On 11/7/23 at 11:42am hospice records indicated that there was a meeting held to discuss suspected fall last week, where it was determined that unexplained injuries and bruises were a result of a fall, the discussion it was unclear if recent decline was due to suspected fall, medication changes or generalized decline, but it raised concerns about limited supervision provided by facility staff, and suggesting hiring temporary staffing for R1 to ensure their safety. Also, there was another incident dated 11/10/2023 revealing that R1 was found by staff on the floor around 12:50pm, later that day R1 pulled the sink out of the wall, broke shower handle and pulled on blinds breaking them as well. On 11/20/23 the hospice agency scheduled R1 for x-rays to be done where results were negative for any fractures. LPA is substantiating not adequate supervision due to findings of main building lock door at night. A finding that the complaint allegation occurs of resident sustained multiple unexplained injuries while in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 21-AS-20231128151806
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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/05/2024
Section Cited
CCR
1569.269(a)(6)
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§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision, & 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:
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The Licensee/Administrator agrees to submit a plan to ensure facility is following up on resident’s needs and observation of the resident to CCL by POC due date to clear the citation. *Immedicate civil penalty issued in the amount of $250 for repeated violation within 12 months (11/2023).
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Based on LPA’s records review and interviews. The facility staff did not ensure that R1 was provided with adequate supervision by locking the back door of the main building blocking R1 from coming inside as well as staff not going to check on R1 every two-three hour as ordered by their physician, which is an immediate risk to the health and safety of 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.
Type A
03/05/2024
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement has not been met as evidence by:
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The Licensee/Administrator agrees to submit a plan regarding timely medical care after resident’s fall and will train staff as to the regulation. Administrator agrees to send proof of training & written fall plan in how to ensure what staff are to do after a fall to CCL by POC due date to clear the citation.
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Based on LPA’s records review and interviews. The facility staff failed to call 911 or other medical personnel as the hospice agency after R1 had a fall and changes of conditions, which poses an immediate health and 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.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 21-AS-20231128151806
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: 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
87411(a)
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87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs...ensure provision of personal assistance & care...This requirement has not been met as evidence by:
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Administrator agrees to submit a written plan in how staff will assist residents with showering & toileting at all times by POC due date.
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Based on interviews conducted and records review. Facility staff did not assist R1 with shower & toileting as ordered by their physician supposedly due to their aggressive behavior after R1 came back from hospital, which poses an immediate risk to the health and safety of the 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.
Request Denied
Type B
03/25/2024
Section Cited
CCR
87464(f)(3)
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87464 Basic Services (f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity…This requirement has not been met as evidenced by
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Facility agrees to submit a planned menu that meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council by POC due date to clear the deficiency.
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Based on LPA’s observation, records review and interviews with the administrator revealing that facility was not providing meals that meet Recommended Dietary Allowances. This is a potential 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.
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
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 21-AS-20231128151806
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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of...(a) Residents in all RCFE shall have all of the following personal rights: (2) To be accorded safe, healthful & comfortable accommodations ...This requirement has not been met as evidence by:
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Administrator agrees to submit a written plan to ensure facility is following up on residents’ needs by POC due date.
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Based on LPAs observation and record review the facility failed to ensure resident's R1 personal rights where met when R1 was found unattended on the floor wearing only pull-up diaper, which poses a potential health and 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
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 21-AS-20231128151806
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: 03/04/2024
NARRATIVE
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Continued from LIC9099C...

Staff did not ensure a resident was provided proper nutrition. Per reporting party, staff did not provide meals to R1 because they said that R1 do not eat, R1 passed away on 11/23/23 and concerns were raised if malnutrition contributed to the R1’s decline. Based on records review, facility communication log starting on 11/6/23 indicates a decline in percentage of meal intake of R1 from 100% to 50%, 11/7/23 – 25% pm shift, 11/13/23 – 0% due to “R1 was sleeping all day”, but another log dated 11/13/23 at 5:30pm R1 ate 25%, 11/14/23 - 20% at 5pm, 11/15/23 – 30% at 5:30pm, 11/16/23 – 30% pm shift, 11/17/23 – 20% dinner, 11/20/23 – 45% pm shift, 11/21/23 – 30% pm shift and 11/22/23 – 0% pm shift. On 11/21/23 the private caregiver reported via text message that facility staff did not bring any water or food the entire night, the facility staff will not provide food or water to R1 unless it was requested by them. Also, outside agency records indicated that on 11/21/23 they reached out to the Administrator to remind them of staff duties with R1. Also, outside agency records revealed a weight loss of 30 lbs. within the last year as follow: 10/25/22 – 180lbs to 9/15/23 – 151lbs. Based on interviews conducted with an outside party, on 11/20/23 they arrived at the facility unannounced at approximate 5:15pm, R1 was found with their legs in the bed and their torso hunched over the chair located next to their bed enabling R1 to move, it was unclear for how long time had been stuck in this position, when staff was asked by what time was the last time that they have checked on R1, they were told that two hours ago (3:15pm), then it was noticed that the entire community was eating, so they asked when dinner was going to be brought to R1, and staff replied to them that R1 was already fed with their dinner at 3:15pm. Per Administrator, it was confirmed that it was brought to their attention about caregivers were not assisting R1 with ADLs including meals due to caregivers were afraid of R1, and the administrator talked to staff to remind them about their duties with R1. Therefore, R1 wasn’t offered snacks and meals contributing to their weight loss. Based on facility communication daily log failed to report it to hospice agency. 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.

The Department will be scheduling a meeting to discuss areas of concern.

Exit interview was conducted with Administrator over the phone and 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
LIC9099 (FAS) - (06/04)
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