Skip to main content

Inspection visit

Follow-up on corrections

WINDCHIME OF MARINLicense 2168009771 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conducted a case management regarding fire clearance issues. During annual inspection on 7/24/2025 LPA observed some resident room windows on the 2 nd and 3 rd floors : that were screwed in closed, and or had safety crank off, not having ability to open if there was an emergency, 90% having infant security locks on screens, and many infant security locks broken off of the screens, not functional at all. Fire clearance at time of inspection (7/24/2025) STD850 approved by Kentfield Fire District dated 8/2019 indicates Window screens shall remain free of keyed locking mechanisms and shall remain readily accessible by First Responders from the exterior. Issues were cross reported to Kentfield Fire District requesting updated STD850. On 9/4/2025 Deputy Fire Marshal Larry Pasero conducted a visit at facility informing facility child locks and screen locks shall be removed to provide access by first responders from the exterior in a rescue situation. On 10/9/2025 Kentfield Deputy Fire Marshal submitted to Community Care Licensing (CCL) Conditional Fire Clearance until 9/18/2026 when window issues must be resolved by. Conditions being; 1) At no time shall any lock, device or equipment be added to the existing windows or window screens that requires special knowledge, tools or effort to open from the interior or exterior. 2) Locking hardware and maintenance of existing non-conforming window openings shall be allowed for one year with conditions. During today’s (10/30/2025) visit, LPA is citing facility for not following their Fire Clearance conditions per regulation 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. **** Immediate Civil Penalties of $500. The following deficiencies were observed (see LIC 809D) 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.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(1)(D)Type B

    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.

  • 87202(a)Type A

    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.

  • 87465(a)(4)Type A

    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.

  • 87464(f)(4)Type A

    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

FAQ · About this visit

Common questions about this visit

What happened during the October 30, 2025 inspection of WINDCHIME OF MARIN?

This was a other inspection of WINDCHIME OF MARIN on October 30, 2025. 1 citation were issued: 1 Type A (serious).

Were any citations issued to WINDCHIME OF MARIN on October 30, 2025?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...(1)A written report shall be submi..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

Share this reportEmail

Next steps

If this is your facility,claim this pageand correct anything the record gets wrong. Free.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.