Windchime of Marin

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...This requirement is not met as evidenced by: Based on observation during Annual inspection and information... received from Local Fire Department, Licensee did not comply with the section cited above by not following fire clearance regarding windows and screens resulting in the fire department providing conditional fire clearance until 9/18/2026 or if prior windows and screens fixed to notify CCL & Fire Dept. This is an immediate risk to residents in care.

87464(f)(4). Basic Services. Basic services shall at a minimum include:...Personal assistance and care as.. indicated in the pre-admission appraisal, …such as dressing, eating, bathing..***Based on documents reviewed and interviews conducted, this requirement was not met as evidenced by: Care report-appraisal for 8/26/2025 indicate R1 was to have 2 showers per week although, there were no shower logs for time frame or notes indicating shower refusals, along with 4 staff interviews indicated R1 not showered 8/26 thru 9/11/2025. This posed an immediate risk to the health and personal rights of R1

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement has not been met based on document review and interviews revealing due to facility writing wrong number of responsible party they were not reached, as well responsible party indicated they never receive written notice of incident report. This is a potential risk to residents in care.

87465 Incidental Medical and Dental Care:(a)A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review, Licensee did not comply with the section cited above and did not ensure that medication was administered to R1 as required. R2 Incident Report stated that PM Med Tech provided wrong medication ??times. This is an immediate health and safety risk to residents in care.

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... This requirement not met by licensee as evidenced by: R1 eloped from facility and was found by Fire Dept approximately 2 hrs later alone outside of facility property, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs observation (see pics) Housekeeping closet was found unlocked with toxic cleaning chemicals including Mold Armor Rapid clean remediation & R3 room LPA observed unlocked bathroom cabinet with razors and supplies (see pics) which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 6 out of 10 resident bathroom faucets were not within regulation temp of 105 to 120 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on records reviewed, Licensee did not ensure R4 received a medical assessment prior to admission. This poses a potential Health, Safety or Personal rights risk to persons in care.

Based on LPA & Administrator's observation, record review and interview the licensee did not comply with the section cited above in not finding any records indiating attached to smoke detection system or carbon monoxide detectors in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

and competency to meet their needs. This requirement not met by licensee as evidenced by: Based on LPA observations, interview and record review, facility is not meeting resident's needs having only 1 caregiver on each of the 2 floors of 26 dememtia residents (10 two person assist & 16 1 person assist) and only 1 med tech, which poses an potential health, safety or personal rights risk to persons in care.

87625(b)(3) Managed Incontinence(b)In addition to Section 87611, General .., the licensee shall be responsible for :(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on statements and observation, this requirement is not met as evidenced by: On 8/22/24 LPA & staff observed 3rd floor of facility and R1 & R2’s rooms having strong incontinence odors. This poses a potential health & safety risk to R1, R2 & other residents in care.

1569.69(a)(1) Medication Administration Training (a)Each residential care facility for the elderly shall ensure that each employee …who assists residents with the self-administration of medications meets all the following training requirements: (1)In facilities licensed for 16 or more.. employee shall complete 24 hours of initial training…consisting of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction..which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Based on: Record review & interview with Administrator, S1 lacks proof of required HSC 1569.69(a)(1) medication training, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation (see pics), licensee did not comply by having a bed frame on 3rd floor east side emergency exit door, restricting ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500.

LPA observed food, half a quiche uncovered in kitchenette drawer, accessible to residents in care, & unwrapped/uncovered ice cream in freezer & uncovered pie from previous day in refrigerator . This is a risk of resident's health & safety and/or a personal rights risk to residents in care.

Based on observation, the licensee did not comply with the section cited above in 2 out of 2 water heating food warmers in 2nd & 3rd floor dementia facility kitchettes were not secured from residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed razors & a pair of scissors and other sharp objects in an unlocked resident bathroom cabinet accessible to residents in care along with a 5 gallon bucket of pain in unlocked staff room in kitchenette. This poses an immediate health, safety or personal rights risk to persons in care.

*Based on observation facility did not maintain facility in good repair by: 3rd floor, black coloring on floor under kitchenette sink where water leak use to be, a missing bedroom door to room 314 & bathroom wall to resident (R1)’s room at all times through out of the facility which poses a potential health, safety risk to clients in care.

Two (2) staff lack proof of required HSC 1569.69(b) medication training, per LPA's file reviews, the licensee did not comply with the section cited above in two out of five file reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.

Two (2) staff lack proof of required annual training, per LPA's file reviews, the licensee did not comply with the section cited above in two out of five files reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:LPA learned that the facility was made aware about the incident in late November 2023 and failed to report to the Department of Social Services-Community Care Licensing Division which presents an immediate health, safety and personal rights risk to the residents in care. As well, CCL has not received any reports from facility since 11/21/2023 (4 weeks), when they use to submit SIR’s Hospice Initiations, Death Reports, & SOC’s weekly.

87355 Criminal Record Clearance- (e) All individuals subject to a criminal record review pursuant to H&S Health and Safety Code Section 1569.17(e) shall prior to...residing...in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by: Based on LPAs record review and interview with Administrator, facility did not ensure private agency caregiver (I1) was fingerprint cleared and had been working at the facility for approximately three months when incident happened and has been let go. This presents an immediate health and safety risk to residents in care.

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:This requirement is not met as evidenced by: Based on LPA record review and interview with Administrator & RCD facility did not ensure to obtain a criminal record clearance for staff (S1) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care.

Based on a review records and interview with RCC it was found that resident (R1) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.

Based on observation, interview and record review, today's visit and verification with CCL: Licensee did not ensure the regulation above due to S2 & S3 who were fingerprint cleared but NOT associated to this facility as required. This is an immediate risk to the Health & Safety of residents in care.

Based on record review conducted on May 15, 2023, the Administrator did not comply with the section cited above in 3 out of 5 staff members who are required, did not have current First Aid as required by Title 22 regulations. This poses an immediate health, safety or personal rights risk to residents in care.