216803891-7-19-2024-21-AS-VBEI-D7HRY2-20240725132533

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803891
Report Date: 07/19/2024
Date Signed: 07/19/2024 11:22:31 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/17/2024 and conducted by Evaluator Helena Rummonds

COMPLAINT CONTROL NUMBER: 21-AS-20240417101040

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: 22	DATE:	07/19/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Erlinda Ferris		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff did not seek timely medical care for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to deliver findings regarding the above allegation. LPA and Administrator discussed the purpose of the visit.
Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents.

Complaint alleges that staff did not seek timely medical care for resident. LPA received a report from facility on 4/15/2024 indicating that Resident 1 (R1) was found not breathing in their room at approximately 4:30AM while NOC shift caregivers were doing their routine rounds. Report states that EMT pronounced R1 deceased at 6:12AM.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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-20240417101040

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MARIN TERRACE	FACILITY NUMBER: 216803891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/20/2024 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	(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...	1 2 3 4 5 6 7	Administrator agrees to submit proof of in-service training for all direct care staff regarding how to determine when to call 911. Proof of training must include: staff names with signatures, dates, topics covered, who conducted the training, etc. Proof to be submitted by POC due date 08/02/24.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: based on document review and interviews conducted, the licensee did not comply with the section cited above by not contacting emergency services in a timely manner.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240417101040

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MARIN TERRACE	FACILITY NUMBER: 216803891
	VISIT DATE: 07/19/2024

NARRATIVE

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Continued from LIC9099

Interviews conducted revealed that caregivers report to medication technicians when there is an emergency, and the med techs determine whether or not they should call 911. Per interviews conducted, caregivers found the resident to be deceased and immediately called the Administrator of the facility. Caregivers had attempted to get in contact with R1s responsible party as they wanted the responsible party’s permission before calling 911. Administrator called Staff 1 (S1) to immediately go to the facility and assess the situation. When S1 arrived to the facility, they immediately called 911. Investigation confirmed that there was a 90 minute delay in calling paramedics due to the facilities procedures for determining when to call emergency services.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED. Deficiencies are 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. Copy of report, LIC-9099D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC9099 (FAS) - (06/04)

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