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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803891
Report Date: 03/10/2026
Date Signed: 03/10/2026 03:56:30 PM

Document Has Been Signed on 03/10/2026 03:56 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/
DIRECTOR:		KATHLEEN DEVERAFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 49CENSUS: 20DATE:
03/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Kathleen Devera (Administrator)TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced required annual inspection of this facility and case management to cite deficiencies discovered during a complaint investigation
#21-AS-20260126092155 met with facility Administrator Kathleen Devera. Annual fees current.

LPA learned through records review and interviews with Administrator while investigating complaint #21-AS-20260126092155 that the facility has failed to follow up when resident (R1) reported to staff (S1, S2 & S3) on 1/19/26 at 2:09pm an alleged “abuse” has occurred. According to the Administrator, R1 has a history of been aggressive to staff, so it was presumed as another unfounded incident. On 12/12/25 there was another incident involving another resident (R2) where it was reported to facility management that staff (S4) was no longer welcome to care for R2 due to their incompetency when providing care and been always in a rush, getting defensive and other complaints that other staff raised about them, which resulted in management conducted an internal investigation and provided a written warning. LPA reviewed incident reports submitted to the Department and there were no incident reports regarding any of these reports.

LPA/Administrator toured the building and grounds: The main building is two stories and currently there are eleven residents residing downstairs and four residents upstairs. Second building is single story and currently there are three residents. There were two staff and housekeeper staff present in the second building providing care and supervision to residents in care. Continue on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 03/10/2026
NARRATIVE
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Continued from LIC809...
At approximately 10:00 am, LPA/Administrator observed that the elevator was last inspected on 11/20/23 and permit expired on 11/20/24. Per Administrator, they just came this week to inspect it, but there was no proof of service given.

At approximately 10:15am, LPA/Administrator while touring the facility did not hear the auditory alarm when opening the door leading to second building located in the back of the facility. Per Administrator, the auditory alarm was not working and its being repaired.

At approximate 10:30am LPA/Administrator observed hot water measurements of 78.8, 77.7, 135.5, 124 and 108.3 degrees which is not within regulation between 105 and 120 degrees F at faucets used by residents in care. Bathrooms have non-skid surfaces and grab bars at the toilet and shower areas. All medications were all locked and inaccessible to residents in care.

Facility has cameras in both buildings in common areas. All common areas, hallways, and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. The facility is on a delayed egress system and a locked perimeter courtyard for resident's use, which it was approved in their fire clearance. Evacuation chair was observed in the stairwell and documented in the facility emergency plan as indicated by the Department. The facility was a comfortable temperature. Passageways were free of obstructions. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom and they are operational to alert staff. The amount of fresh and nonperishable foods is within regulation. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary. Refrigerators and freezers were at required temperatures. Prepared and left over foods were covered and labeled. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The facility has a generator in case of power outages.
Continue on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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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: 03/10/2026
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Continued from LIC809C...
Residents were observed participating in group activities in common areas. Fire extinguishers inspected were charged and dated 3/18/2025. Smoke detectors were tested in resident rooms. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present and operational. The last disaster drill was conducted on 2/3/26. There were two garbage cans that do not have a lid/cover and ant observed in main bathroom located in the second building in the back of the facility (technical violation issued).

At 11:00 AM, LPA conducted a file review of ten residents and five staff. One out of five staff (S4) do not have a health screening form on file including their TB test (technical violation issued). Three out of five staff (S1, S3 & S5) do not have current 1st aid or CPR certificates updated. All staff have completed all required training hours. Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. One out of ten residents (R2) does not have half bed rails order on file (technical violation issued). Kathleen Devera, administrator certificate 6069816740 expires on 10/18/2026. Medication is centrally stored and locked in medication cart located at the medication room. A sample of medication and medication records reviewed.

Updated copies of the following documents need to be submitted to CCL by not later than 3/23/26:


LIC500- Personnel Report.
LIC308- Designation of Responsibility.
LIC610E- Disaster Plan (if there are any changes).
Evidence of Liability Insurance.
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given. Exit interview was conducted with Administrator and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2026 03:56 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/10/2026 at 03:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARIN TERRACE
FACILITY NUMBER: 216803891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)

87303(e)(3) Maintenance and Operation Taps delivering water at 125 degree F (52 degree C) or above shall be prominently identified by warning signs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the temperature reading of hot water facets not used by residents, the kitchen sink facet reading was 135.5 and 124 in the bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
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Administrator agrees to place warning signs for faucets delivering water 125 or above. To clear this violation, Administrator will submit photo proof of each faucet identified in this report with a warning sign placed near the facet to warn the user of the hot water temperature. Photos to be submitted to CCL by POC date by 3/11/26
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2026 03:56 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/10/2026 at 03:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARIN TERRACE
FACILITY NUMBER: 216803891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports.: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s record review and interviews with the Administrator, the facility failed to notify the Department about R1’s and R2’s incidents, which could pose a potential risk to the health and safety of residents in care.
POC Due Date: 03/24/2026
Plan of Correction
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The Administrator agrees to review reporting requirements regulation, conduct training with all staff about reporting requirements, and will submit a written policy about the process that staff will follow to ensure that incidents are reported timely to CCL as proof of correction to clear the deficiency by POC due date 3/24/26.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation and interview, the licensee did not comply with the section cited above in elevator was last inspected on 11/20/23 and permit expired on 11/20/24. Also, the auditory alarm when opening the door leading to second building located in the back of the facility was not working which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2026
Plan of Correction
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Licensee shall submit self-certification (LIC9098) they have read and understand Regulation 87303. Self-certification shall be submitted to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2026 03:56 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/10/2026 at 03:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARIN TERRACE
FACILITY NUMBER: 216803891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 3 out of 5 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.
POC Due Date: 03/24/2026
Plan of Correction
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Administrator to ensure that at least one staff on duty has CPR training at all times & all staff have First Aid. Administrator to submit self-certification form (LIC9098) ensuring that staff have current CPR trained per regulation by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
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