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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803891
Report Date: 10/15/2024
Date Signed: 10/15/2024 10:46:58 AM

Unsubstantiated


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
07/01/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240701143513
FACILITY NAME:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:ERLINDA FERRISFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: 24DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erlinda FerrisTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not meet resident's incontinence needs
Staff take away a resident's night call button
INVESTIGATION FINDINGS:
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Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken, documents obtained and reviewed as well as site visits made to the facility. The following determinations are made: Complainant alleges that facility staff took resident's ( R1's) call button from R1 and that photos exist that show R1's incontinent needs were not met; R1 denies staff took R1's call button; Complainant has not produced photos of R1's neglected incontinent needs; R1's Physician's Assessment dated 6/2/2024 does not indicate R1 is incontinent; R1 states that staff did not meet R1's incontinent needs; Facility Administration state R1 requested incontinent briefs in order to avoid getting out of bed at night. Although the allegation may be true, based upon the statements and documents, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED.

Report Left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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 3
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
07/01/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240701143513

FACILITY NAME:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:ERLINDA FERRISFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: 24DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erlinda FerrisTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Staff mishandled a resident’s medication
INVESTIGATION FINDINGS:
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Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken, documents obtained and reviewed as well as site visits made to the facility. The following determinations are made: Complainant states that Complainant observed a pill in R1’s room that was identified as not prescribed by R1’s physician and not listed on the facility’s Medication Administration Record for R1; R1 states that the pill was melatonin and that it was given to R1 by a Staff person as a sleep aid. Based upon the statements, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240701143513
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: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2024
Section Cited
CCR
87465(e)
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87465(e) Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and
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Cleared at time of visit. Facility has provided refresher training to staff on the requirements of 87465.
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a label on the medication… Based upon statements, this requirement not met as evidenced by: An OTC sleep aid was observed in R1’s room which was not prescribed by R1’s physician. This posed an immediate risk to R1’s health.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3