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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803891
Report Date: 12/16/2022
Date Signed: 12/16/2022 12:32:52 PM

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
11/14/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20221114080118
FACILITY NAME:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:WILLIAMS, DARNELLFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: 17DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Resident Care Coordinator, Stacy PlasterTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not meeting resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Marin Terrace for the purpose of conducting interviews and delivering findings. LPA met with Resident Care Coordinator, Stacy Plaster and was granted access into the facility. Interim Administrator arrived one hour later.

During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties including but not limited to responsible parties and witnesses.

Complaint alleges that staff are not meeting resident's needs. During the delivery of findings, LPA conducted additional interviews with staff and residents. LPA reviewed the Level of Care document dated for June 26, 2022, and learmed that Resident #1 was supposed to have two person assist bathes. Furthermore, no where on the document does it indicate sponge bathes.

(Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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 5
Control Number 21-AS-20221114080118
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: 12/16/2022
NARRATIVE
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In addition, LPA reviewed additional facility documents and learned that Resident #1 was admitted in Mid-May 2022 and had a Level of Care change in August 2022 that was not properly documented on paper (See LIC 809). Furthermore, during the course of the investigation, LPA learned that an Admission Agreement was not properly retained in Resident #1's file (See LIC 809).

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 repeated deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were emailed along with this report.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20221114080118
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: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
87464(f)(4)
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87464(f)(4)-Basic Services:
(f) Basic services shall at a minimum include:
(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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Plan of Correction shall include following the Level of Care document and conduct staff training. In addition, Licensee/Administrator shall provide a written summary on how future compliance will be met moving forward.
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This requirement was not met as evidenced by:

Based off document reviews of the Level of Care plan, the document indicated that the resident will be receiving regular bathes via two staff members and not sponge bathes. This regulation is a potential health, safety and personal rights risk to resident(s) in care.
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Plan of Correction due date for staff training and written summary:

December 23, 2022.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/14/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20221114080118

FACILITY NAME:MARIN TERRACEFACILITY NUMBER:
216803891
ADMINISTRATOR:WILLIAMS, DARNELLFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: 17DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Resident Care Coordinator, Stacy PlasterTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident's personal rights are being violated.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Marin Terrace for the purpose of conducting interviews and delivering findings. LPA met with Resident Care Coordinator, Stacy Plaster and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties including but not limited to responsible parties and witnesses. Interim Administrator arrived one hour later.

Complaint alleges that Resident's personal rights are being violated. During the delivery of findings, LPA conducted additional interviews with staff. LPA could not prove or disprove that Facility staff are violating personal rights of resident(s) in care. In addition, facility documents were reviewed during the course of the investigation. LPA could not corroborate the allegation.

(Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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 5
Control Number 21-AS-20221114080118
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: 12/16/2022
NARRATIVE
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However, during the course of the investigation, LPA identified that Licensing was not notified in a timely manner regarding a resident concern of suspected abuse nor was the proper paperwork submitted to Licensing (See LIC 809).

A finding that the complaint allegation of Resident's personal rights are being violated is unsubstantiated meaning that although the allegation 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. Exit interview was conducted and a copy of this was report was signed and given Resident Services Coordinator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5