Inspection Report Summary
Most inspections found deficiencies related to safety and compliance, with several substantiated complaints involving untrained staff dispensing medications, unsecured exits leading to resident elopement, and failure to maintain required criminal background clearances for caregivers. The facility received immediate civil penalties totaling $1,500 across multiple reports for fire clearance violations and allowing unapproved staff to work. Other common issues included unlocked toxic chemicals and sharp objects accessible to residents, inadequate staffing levels, and environmental concerns such as mal odors and hot water temperature violations. Several complaint investigations were unsubstantiated, including allegations about resident care and cleanliness. The most recent inspection on October 30, 2025, cited a deficiency for not maintaining fire clearance conditions and resulted in a $500 fine, indicating ongoing challenges with fire safety despite some corrective actions over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
49% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Census: 27
Capacity: 55
Deficiencies: 1
Date: Oct 30, 2025
Visit Reason
The visit was a case management inspection related to deficiencies concerning fire clearance issues, following up on previous findings from the annual inspection and fire department conditional clearance.
Findings
The facility was cited for not complying with fire clearance conditions approved by the local fire department, specifically regarding window and screen locks that impede emergency access. Immediate civil penalties of $500 were issued due to the risk posed to residents.
Deficiencies (1)
Failure to maintain a fire clearance approved by the city, county, or fire department, specifically due to window and screen locks that restrict emergency access.
Report Facts
Civil penalty amount: 500
Plan of Correction due date: Oct 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Cottman | Administrator | Met with during inspection and named in report |
| Shannan Hansen | Licensing Program Analyst | Conducted inspection and signed report |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 55
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The visit was an unannounced Case Management - Incident Visit to follow up on a self-reported incident involving a resident who eloped from the facility.
Complaint Details
The visit was complaint-related, following a self-reported incident of resident elopement. The incident was substantiated as the resident was found outside the facility after eloping through an unsecured exit.
Findings
The resident with dementia eloped from the facility through an unlocked emergency exit door and was found by the fire department approximately two hours later. Two doors were found unlocked and one emergency exit alarm was turned off, posing an immediate health and safety risk. A deficiency was cited for failure to ensure proper monitoring of exits for residents at risk of elopement.
Deficiencies (1)
Failure to ensure the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to residents at risk for elopement, as evidenced by a resident eloping and being found outside the facility.
Report Facts
Plan of Correction Due Date: Sep 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Cottman | Administrator | Met with during the inspection and named in the incident report |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 26
Capacity: 55
Deficiencies: 5
Date: Jul 24, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements for this Residential Care Facility for the Elderly (RCFE) serving residents with dementia.
Findings
The inspection found multiple deficiencies including unlocked storage of toxic chemicals and razors posing immediate risk, insufficient caregiver staffing for residents with high care needs, lack of carbon monoxide detectors, hot water temperatures out of regulatory range in several rooms, and missing medical assessment documentation for one resident. Other areas such as medication storage, fire safety equipment, and staff certifications were found compliant.
Deficiencies (5)
Housekeeping closet was found unlocked with toxic cleaning chemicals and an unlocked bathroom cabinet with razors and supplies posing immediate health and safety risk.
Facility did not meet staffing requirements with only one caregiver on each of two floors for 26 dementia residents, posing potential health and safety risk.
No records or presence of carbon monoxide detectors attached to smoke detection system found, posing potential health and safety risk.
Six out of ten resident bathroom faucets had hot water temperatures outside the regulatory range of 105 to 120 degrees Fahrenheit.
One out of six residents did not have a medical assessment documented prior to admission.
Report Facts
Residents: 26
Total Capacity: 55
Residents under Hospice care: 4
Deficiencies cited: 5
Residents requiring two person assist: 10
Residents requiring one person assist: 16
Hot water faucets out of range: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Cottman | Administrator | Met during inspection and named in staffing and certification findings |
| Ravi Banwait | Business Office Director | Met during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 55
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-03-19 regarding resident care and facility practices at Windchime of Marin.
Complaint Details
The complaint investigation addressed allegations that staff did not safeguard a resident's personal belongings, did not bathe a resident, obtained caregiving services without consent from the resident's responsible party, and did not allow the resident's responsible party to use a medical pharmacy of their choice. All allegations were determined to be unsubstantiated or unfounded based on evidence and interviews.
Findings
All allegations investigated were found to be unsubstantiated or unfounded after interviews, record reviews, and observations. No deficiencies were cited during the visit.
Report Facts
Capacity: 55
Census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
| Ravi Banwait | Business Office Director | Met with Licensing Program Analyst during investigation |
| Mary McClure | Administrator | Facility Administrator mentioned in report |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 55
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The inspection was conducted as a Case Management inspection following an incident report submitted by the facility regarding a medication error involving Resident 1.
Complaint Details
The visit was complaint-related due to a medication error incident report. The incident involved a medication order change that was not initially followed correctly, but was corrected upon receipt of the new medication. The complaint was not substantiated as no deficiencies were cited.
Findings
The review found that the medication error involved administration of both old and new medications on certain dates, but the new medication was appropriately administered once received and there was no overlap. No deficiencies were cited.
Report Facts
Capacity: 55
Census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Cottman | Executive Director | Met with Licensing Program Analysts during inspection |
| Parinda Kleinberg | Resident Care Director | Involved in reviewing medication orders and incident report |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 55
Deficiencies: 2
Date: Aug 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-06-20 regarding untrained staff dispensing medications, facility mal odors, and cleanliness of residents' rooms.
Complaint Details
The complaint investigation was substantiated for allegations that untrained staff dispensed medications and that staff did not ensure the facility was kept free of mal odors. The allegation regarding unsafe, unclean, and unsanitary resident rooms was unsubstantiated.
Findings
The investigation substantiated two allegations: untrained staff dispensing medications and staff not ensuring the facility is kept free of mal odors due to housekeeping issues. The allegation that staff do not ensure residents' rooms are kept in safe, clean, sanitary conditions was unsubstantiated.
Deficiencies (2)
Staff allowed untrained employee (S1) to dispense medications without required initial medication training hours.
Facility failed to keep the environment free of odors from incontinence due to insufficient housekeeping, especially on Sundays.
Report Facts
Capacity: 55
Census: 28
Plan of Correction Due Date: Aug 20, 2024
Medication Training Hours Required: 24
Hands-on Shadowing Training Hours: 16
Other Training Hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary McClure | Administrator | Met with Licensing Program Analyst during investigation and involved in findings |
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 55
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations received on 2024-05-20 regarding unsanitary resident rooms, inadequate incontinence care, and unsafe food service practices at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unsanitary resident rooms, inadequate incontinence care, and unsafe food service practices. Inspections and staff interviews did not support these claims.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Resident rooms were observed to be clean, incontinence supplies were adequately stocked and managed, and the kitchen was clean and organized with no enforced requirement for hair nets. All allegations were deemed unsubstantiated.
Report Facts
Complaint Control Number: 21-AS-20240520093428
Number of resident rooms inspected: 9
Number of staff interviewed: 4
Number of hospice employees interviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
| Ravi Banwait | Business Office Director | Met with Licensing Program Analyst during investigation |
| Mary McClure | Administrator | Named as facility administrator, unavailable during investigation |
Inspection Report
Annual Inspection
Census: 26
Capacity: 55
Deficiencies: 7
Date: May 30, 2024
Visit Reason
Unannounced annual inspection to evaluate compliance with regulations for a memory care facility.
Findings
The inspection found multiple deficiencies including fire safety violations due to obstructed exits, unsecured sharp objects accessible to residents, incomplete staff training records, uncovered food items, unsecured food warming devices, and facility maintenance issues such as water damage and missing doors. An immediate civil penalty of $500 was assessed for the fire safety violation.
Deficiencies (7)
Razors and scissors in an unlocked resident bathroom cabinet accessible to residents, along with a 5 gallon bucket of paint in an unlocked staff room.
Bed frame obstructing 3rd floor east side emergency exit door restricting resident exit.
Two staff lacked proof of required annual dementia care training.
Uncovered food items including quiche, ice cream, and pie stored improperly in kitchenette and refrigerator.
Two water heating food warmers in dementia facility kitchenettes were not secured from residents.
Two staff lacked proof of required annual medication training.
Facility not maintained in good repair: black coloring on floor under kitchenette sink from water leak, missing bedroom door to room 314, and missing bathroom wall to resident's room.
Report Facts
Immediate Civil Penalty: 500
Staff records reviewed: 5
Residents medication records reviewed: 2
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary McClure | Administrator | Met during inspection and named in relation to facility compliance |
| Ravi Banwait | Business Office Director | Met during inspection and involved in moving hazardous items |
| Shannan Hansen | License Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 26
Capacity: 55
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted as a required one-year visit to evaluate the facility's compliance with regulations.
Findings
The facility was toured and found to have comfortable temperatures, unobstructed exits except one fire exit door, proper hot water temperatures, necessary safety features in bathrooms, adequate food supplies handled safely, and posted activity schedules. However, the License Program Analyst was unable to complete file reviews, medication review, and interviews, and will return to complete the inspection. No citations were given at this inspection.
Report Facts
Residents under Hospice care: 5
Resident apartments toured: 9
Rooms tested for hot water temperature: 9
Resident files reviewed: 5
Personnel files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ravi Banwait | Business Office Director | Met during inspection and authorized signing of report |
| Mary McClure | Administrator | Administrator who was unavailable for inspection but authorized report signing |
| Shannan Hansen | License Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report |
| Gisselle Benavides | Care Coordinator | Accompanied the tour of the facility |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 55
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff do not ensure residents are allowed to leave their rooms, staff are unable to communicate with residents, and residents' care needs are not being met.
Complaint Details
The complaint investigation was unannounced and addressed three allegations: residents being locked in rooms, staff communication issues, and unmet care needs. After interviews, observations, and record reviews, all allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff lock residents' doors as a safety precaution but residents can exit locked rooms from the inside. Staff were observed communicating with residents effectively despite dementia challenges. Care needs were documented as being met with regular bed checks and no negative effects noted.
Report Facts
Capacity: 55
Census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Met with Licensing Program Analyst during investigation |
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 55
Deficiencies: 2
Date: Dec 14, 2023
Visit Reason
The visit was an unannounced case management inspection triggered by information received about a resident being assaulted by a caregiver and failure of the facility to notify the licensing agency as required.
Complaint Details
The complaint involved a resident (R1) being assaulted by a caregiver. The facility did not notify the licensing agency within 7 days as required. The caregiver (I1) was not DOJ background cleared and had worked at the facility for approximately three months before being terminated.
Findings
The facility failed to report an incident involving resident assault within the required 7 days and did not submit incident reports since 11/21/2023. Additionally, a caregiver was found to have worked without required DOJ background clearance, resulting in a citation and civil penalty.
Deficiencies (2)
Failure to report incidents to the licensing agency within seven days as required by regulation 87211(a)(1)(D).
Failure to ensure that an individual caregiver had DOJ criminal record clearance prior to working at the facility as required by regulation 87355(e)(1).
Report Facts
Civil Penalty Amount: 500
Last Incident Report Date: Nov 21, 2023
Plan of Correction Due Date: Dec 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Named in relation to failure to report incidents and lack of communication within facility |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and issued citations |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 55
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as a case management follow-up on an SOC 341 form reporting an incident where outside agency staff (S1) was witnessed striking a resident (R1) on the side of the head with a closed fist.
Complaint Details
The visit was complaint-related based on an SOC 341 form reporting an incident on 08/05/2023 where outside agency staff (S1) struck a resident (R1). Law enforcement removed S1 from the facility. The complaint was substantiated by the finding that S1 worked without criminal clearance.
Findings
The facility allowed a person (S1) to work and provide care to residents without obtaining a required criminal record clearance, posing an immediate health, safety, and personal rights risk to residents. Civil penalties totaling $500 were assessed for this violation.
Deficiencies (1)
Facility did not ensure to obtain a criminal record clearance for staff (S1) prior to work, reside or provide care to residents, posing an immediate health, safety and personal rights risk.
Report Facts
Civil penalty amount: 500
Civil penalty daily rate: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Named in relation to the finding about staff working without clearance. |
| Ashley Perrone | Resident Care Director | Named in relation to the finding about staff working without clearance. |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and cited deficiencies. |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 55
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
Unannounced visit/investigation of a complaint alleging the facility failed to ensure a resident takes their medications as prescribed by their physician.
Complaint Details
Complaint alleges facility failed to ensure resident was assisted with medication refill causing them to not have medication for two weeks. The allegation was unsubstantiated.
Findings
The facility failed to ensure a resident was assisted with medication refill causing them to not have medication for two weeks. Attempts to identify the resident's primary physician and obtain new prescriptions were unsuccessful. The allegation was unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Facility failed to ensure resident takes their medications as prescribed by their Physician.
Report Facts
Capacity: 55
Census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Met with Licensing Program Analyst during complaint investigation. |
| Ashley Perrone | Resident Care Director | Met with Licensing Program Analyst during complaint investigation. |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation. |
| Hope DeBenedetti | Licensing Program Manager | Named in report header. |
Inspection Report
Follow-Up
Census: 25
Capacity: 55
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The visit was an unannounced case management inspection to follow up on an SOC341 and a self-reported incident submitted to Community Care Licensing on 6/23/2023 regarding an attempted sexual encounter between residents and another individual.
Findings
The facility separated and redirected the involved individuals, contacted appropriate parties including law enforcement and Adult Protective Services, relocated one resident to a different room, and increased supervision. No deficiencies were cited during the inspection.
Report Facts
Incident report date: Jun 20, 2023
Incident report submission date: Jun 23, 2023
Meeting date: Jun 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Met with Licensing Program Analyst during inspection and involved in incident follow-up |
| Ashley Perrone | Resident Care Director | Met with Licensing Program Analyst during inspection and involved in incident follow-up |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 29
Capacity: 55
Deficiencies: 3
Date: May 15, 2023
Visit Reason
Unannounced annual inspection and case management continuation visit to evaluate compliance with regulations and follow up on a self-reported elopement incident.
Findings
The inspection revealed deficiencies including three staff lacking current First Aid certification, two staff not properly associated with the facility per criminal record clearance regulations, and a resident elopement incident resulting in a citation. The facility has taken corrective actions including staff termination, increased staffing, electrical repairs, and in-service training.
Deficiencies (3)
Three of five staff required to have First Aid certification did not have current certification as required by Title 22 regulations.
Two staff members were fingerprint cleared but not associated with the facility as required by Title 22 regulations.
Resident with dementia eloped from the facility without staff knowledge, posing immediate risk to health and safety.
Report Facts
Staff lacking First Aid certification: 3
Staff not associated with facility: 2
Facility capacity: 55
Resident census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Met during inspection and named in findings |
| Shannan Hansen | License Program Analyst | Conducted inspection and authored report |
| Bethany Moellers | License Program Manager | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 29
Capacity: 55
Deficiencies: 0
Date: May 12, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was toured and inspected, including resident apartments, activity rooms, dining areas, and safety systems. Conditions such as temperature, food storage, and safety equipment were found to be in compliance. However, the inspection was incomplete as medication review and some interviews could not be conducted and will be completed at a later date.
Report Facts
Residents under Hospice care: 7
Resident files reviewed: 5
Personnel files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gary Forer | Director of Sales & Marketing | Met during inspection and greeted Licensing Program Analyst |
| Ashley Perrone | Resident Care Director | Met during inspection and signed report in absence of Administrator |
| Jason James | Building Services Director | Accompanied Licensing Program Analyst during facility tour |
| Shannan Hansen | License Program Analyst | Conducted the unannounced annual inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 55
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident sustained an unexplained injury while in care.
Complaint Details
The complaint alleged that a resident sustained unexplained injury while in care. The investigation included interviews, observations, and record reviews. The allegation was found to be unsubstantiated.
Findings
The investigation found that although the resident had bruising, there was no preponderance of evidence to prove the alleged violation occurred. The bruising was possibly related to medication or the resident's susceptibility to bruising, and the allegation was unsubstantiated.
Report Facts
Capacity: 55
Census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Shannan Hansen | Licensing Program Analyst | Conducted complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 31
Capacity: 55
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
The inspection was an unannounced case management visit to follow up on an SOC 341 form and two self-reported incident reports submitted to Community Care Licensing on 10/3/2022.
Findings
The inspection found no deficiencies. The incidents involved aggressive behavior by resident R1 towards resident R2 and staff, resulting in hospital evaluations. The facility is working with the resident's PCP and responsible parties.
Report Facts
Incident dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Met during inspection and involved in case management |
| Ashley Perrone | Resident Care Director | Met during inspection and provided information about resident care and PCP meetings |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 31
Capacity: 55
Deficiencies: 0
Date: Sep 13, 2022
Visit Reason
The inspection was an unannounced case management visit to follow up on three self-reported SOC 341 incidents involving a dementia resident that occurred on 08/30/2022.
Findings
The report details three separate incidents involving resident R1 exhibiting aggressive behavior towards other residents and staff on 08/30/2022, resulting in no injuries but requiring hospital evaluation for R1. The facility notified the family and indicated R1 will not return.
Report Facts
Number of SOC 341 reports: 3
Incident date: Aug 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Oxford | Administrator | Met with Licensing Program Analyst during inspection and involved in incident management |
| Tony Ibarra Jr. | Business Office Director | Met with Licensing Program Analyst during inspection and involved in incident management |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 55
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that resident's records were not being provided when requested by an authorized representative.
Complaint Details
Complaint alleged resident’s records were not provided upon request by an authorized representative. The investigation included review of records, observations, and interviews. The allegation was found unsubstantiated.
Findings
The investigation found that the facility was not intentionally withholding records; delays were due to communication lapses. Records were eventually provided once the requestor supplied a signed legal document and a clear means to receive the records. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 55
Census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kari Oxford | Executive Director | Met with Licensing Program Analyst during investigation |
| Tony Ibarra Jr. | Business Office Director | Interviewed regarding complaint and records request |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 55
Deficiencies: 0
Date: Jun 30, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that a resident sustained an unexplained injury while in care.
Complaint Details
Complaint alleged a resident sustained an unexplained injury while in care. Investigation included record review, observations, and interviews. The resident was found to have a fall-related right hip fracture. The allegation was unsubstantiated.
Findings
The investigation found that the resident's injury was not unexplained but most likely caused by a fall. Records and interviews indicated the resident had a fall resulting in a fractured right hip, and the allegation was unsubstantiated due to lack of preponderance of evidence proving a violation.
Report Facts
Capacity: 55
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Deborah Savoie | Interim Administrator | Met with Licensing Program Analyst during investigation |
| Tony Ibarra Jr. | Business Office Director | Met with Licensing Program Analyst during investigation |
| Brittany Karlinski | Administrator | Facility Administrator named in report header |
Inspection Report
Annual Inspection
Census: 33
Capacity: 55
Deficiencies: 3
Date: May 26, 2022
Visit Reason
An unannounced Annual Required – 1 year Infection Control inspection was conducted to evaluate compliance with regulations and infection control measures.
Findings
The facility was generally clean and well-maintained with adequate food supplies and safety measures; however, several deficiencies were noted including toxins and sharp objects accessible to residents, and hot water temperatures exceeding regulatory limits in most resident bathrooms.
Deficiencies (3)
Toxins such as Lysol and nail polish remover were found accessible to residents in unlocked cabinets and nightstands.
Sharp objects including razors, nail clippers, and scissors were found unlocked in a resident's bathroom, posing a safety risk.
Hot water temperature in 7 of 9 resident bathrooms measured between 121.8 and 124.5 degrees F, exceeding the acceptable range of 105 to 120 degrees F.
Report Facts
Residents on Hospice: 7
30-day medication supply: 30
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tony Ibarra Jr. | Business Office Director | Met during inspection and involved in inspection process |
| Loata Taole | Resident Care Director | Met during inspection and involved in inspection process |
| Brittany Karlinski | Administrator | Facility Administrator who removed hazardous items during inspection and responsible for corrective actions |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 31
Capacity: 55
Deficiencies: 0
Date: Sep 17, 2021
Visit Reason
The inspection was an unannounced case management follow-up visit to investigate a self-reported incident involving a resident and staff interaction reported on 09/01/2021.
Complaint Details
The visit was complaint-related based on a self-reported incident alleging a resident pushed a staff member during an activity. The complaint was investigated and no deficiencies were found.
Findings
The investigation found that during a painting activity, a resident became agitated when staff attempted to clean paint off their face, resulting in the resident pushing the staff member. The facility conducted an internal investigation and planned staff training on reporting requirements. No deficiencies were issued during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator | Met with Licensing Program Analyst during inspection and conducted internal investigation related to incident. |
Inspection Report
Annual Inspection
Census: 63
Capacity: 55
Deficiencies: 0
Date: Jun 25, 2021
Visit Reason
The inspection visit was an unannounced Required - 1 Year inspection of the facility conducted by Licensing Program Analysts to evaluate compliance with regulations.
Findings
The facility was found to be clean, with all exits unobstructed and sufficient food supplies. Kitchen staff were observed improperly wearing masks and not using gloves, and guidance was provided. No deficiencies were cited during the inspection.
Report Facts
Facility census: 63
Facility capacity: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tony Ibarra | Interim Executive Director | Met with Licensing Program Analysts during the inspection |
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