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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 10:42:17 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
09/11/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240911120712
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 did not meet a resident's incontinence needs
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: It is alleged that staff did not meet resident's (R1's) incontinent needs and that staff mishandled R1's medication; This investigation found no evidence of neglected incontinent needs for R1; Medication Administration Record for R1 suggests that one dose of a topical creme prescribed for R1 was not administered; Administration states that the dose was administered but not recorded due to a miscommunication between the staff administering the medications to residents. Although the allegations may be true, based on the statements and documents reviewed, 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
09/11/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240911120712

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 did not address a resident's change in medical condition
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 R1 developed a rash and that staff did not address the condition; Statements taken during the course of this investigation as well as Facility’s Unusual incident/Injury report dated 9/12/2024 indicate that R1 sustained the rash for approximately 4 weeks prior to arrangements made to seek medical attention for R1. Based upon the statements and documents reviewed, the preponderance of evidence standard had 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-20240911120712
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
10/22/2024
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***Based on statements and documents, this requirement not met as evidenced by: R1

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Administration to review the requirements of 87465 and will submit a written declaration confirming compliance to CCL by POC date in order to clear the deficiency.
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sustained rash for approximately 4 weeks prior to receiving medical treatment arranged by facility. This posed an immediate risk to the health of R1.
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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