Windchime of Marin

FACILITY EVALUATION REPORT

FACILITY EVALUATION REPORT

The facility underwent a Case Management - Incident Visit to follow up on a previous report. The Licensing Program Analyst reviewed records and interviewed staff, noting that the facility followed established protocols during the incident. No deficiencies were cited during this visit.

The inspection was a Case Management visit following previous findings regarding fire clearance issues. The primary deficiency cited is the failure to maintain current fire clearance documentation as required by CCR 87202(a). This deficiency is classified as Type A due to the immediate risk posed to residents.

The inspection was a Case Management visit following previous findings regarding fire clearance issues. The primary deficiency cited is the failure to maintain current fire clearance documentation as required by CCR 87202(a). This deficiency is classified as Type A due to the immediate risk posed to residents.

The inspection was a Case Management follow-up regarding a self-reported elopement incident. Two Type A deficiencies were cited related to inadequate monitoring of exits and the actual elopement event itself. Immediate corrective action is required to prevent future safety risks to residents.

The inspection revealed multiple deficiencies across several critical areas, including immediate safety hazards from unsecured toxic chemicals and sharp objects (Type A). Significant concerns were noted regarding staffing ratios and the lack of proper carbon monoxide detection records (Type A/B). Other deficiencies cited relate to plumbing temperature regulation and missing required medical assessments for residents (Type B).

This report details a complaint investigation regarding alleged failures in resident incontinence care. The investigation found that the original allegations were unsubstantiated based on record review, interviews, and facility observations. No deficiencies were cited during the visit.