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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803891
Report Date: 01/10/2023
Date Signed: 01/10/2023 02:09:25 PM


Document Has Been Signed on 01/10/2023 02:09 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:WILLIAMS, DARNELLFACILITY TYPE:
740
ADDRESS:297 MILLER AVETELEPHONE:
(415) 388-9526
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:49CENSUS: DATE:
01/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Interim Administrator, Tom EisemanTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Marin Terrace for the purpose of conducting a Case Management-Deficiency inspection and clearing out a POC. Upon arrival, LPA was greeted by Interim Administrator, Tom Eiseman.

During the POC inspection, LPA observed the kitchen staff sign-in sheet regarding staff training. LPA observed both kitchen staff members signature on the document. Therefore, this Plan of Correction (POC) has been cleared.

However, during the Case Management-Deficiencies inspection, it was disclosed that the Level of Care plan was misplaced and not in the residents file. This deficiency was previously issued on December 16, 2022. As of January 10, 2023, record keeping and the associated training(s) with staff has still not been completed as outlined in the Plan of Correction. Therefore, Civil Penalties will be assessed today.

***An immediate civil penalty has been issued for a Repeat Violations and Failure to Correct the deficiency of California Code of Regulations (CCRs) Section 87506(a)-Record Keeping.***

Exit interview conducted. Copy of report, LIC-809D, LIC-421FC, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. LPA emailed all documents due to printer issues. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. 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: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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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Document Has Been Signed on 01/10/2023 02:09 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited

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87506(a)-Record Keeping:
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement was not met as evidenced by:
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Plan of Correction along with ALL training due on January 13, 2023.

Plan of Correction shall include updating ALL resident records and provide staff training.
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Based on observation, during the Case Management-Deficiency inspection, LPA re-reviewed Resident #1's file and observed that there was no updated Care Plan in the resident record. Furthermore, this was previously cited on December 16, 2022 on Record Keeping.
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In addtiion, Licensee/Administrator shall provide a written summary on how future compliance will be met.

**Civil Penalty Assessed in the amount of $250.00**

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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: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
LIC809 (FAS) - (06/04)
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