Marin Terrace

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Kathleen Devera, Administrator. An allegation regarding staff mismanaged resident medication. The Reporting Party stated that the facility is not documenting of medications administered, both routine and PRN including antipsychotics and opioid medications, bowel movements, objective findings during the care of R1, then for at least a week upon admission, staff were unable to secure appropriate medications and monitoring equipment, such as glucometer, that were prescribed to R1 after been discharged from the hospital. Based on interviews conducted with Administrator and facility medication technician (S6), they acknowledge that R1 has a diagnosis of diabetes, they confirmed that they received on 12/30/25 R1’s one touch glucometer, lancing device, test strips, but no lancets and R1 is unable to check their own glucose, bRead the full finding— CDSS inspection report, March 10, 2026 · control 21-AS-20260126092155

Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken, documents obtained and reviewed as well as site visits made to the facility. The following determinations are made: Complainant alleges that facility staff took resident's ( R1's) call button from R1 and that photos exist that show R1's incontinent needs were not met; R1 denies staff took R1's call button; Complainant has not produced photos of R1's neglected incontinent needs; R1's Physician's Assessment dated 6/2/2024 does not indicate R1 is incontinent; R1 states that staff did not meet R1's incontinent needs; Facility Administration state R1 requested incontinent briefs in order to avoid getting out of bed at night. Although the allegation may be true, based upon the statements and documents, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTRead the full finding— CDSS inspection report, October 15, 2024 · control 21-AS-20240701143513

Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken, documents obtained and reviewed as well as site visits made to the facility. The following determinations are made: It is alleged that staff did not meet resident's (R1's) incontinent needs and that staff mishandled R1's medication; This investigation found no evidence of neglected incontinent needs for R1; Medication Administration Record for R1 suggests that one dose of a topical creme prescribed for R1 was not administered; Administration states that the dose was administered but not recorded due to a miscommunication between the staff administering the medications to residents. Although the allegations may be true, based on the statements and documents reviewed, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left. UnsubstaRead the full finding— CDSS inspection report, October 15, 2024 · control 21-AS-20240911120712

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to deliver findings regarding the above allegation. LPA and Administrator discussed the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents. Complaint alleges that staff did not seek timely medical care for resident. LPA received a report from facility on 4/15/2024 indicating that Resident 1 (R1) was found not breathing in their room at approximately 4:30AM while NOC shift caregivers were doing their routine rounds. Report states that EMT pronounced R1 deceased at 6:12AM. Continued on LIC9099C SubstantiatedRead the full finding— CDSS inspection report, July 19, 2024 · control 21-AS-20240417101040

Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Nickolas Thompson, lead med-technician. Administrator Erlinda Ferris was off for the day, but she was available by phone and gave authorization for staff to sign the report. There is an allegation staff did not provide adequate supervision to resident in care. Per the reporting party, R1 was left with part of their body outside of the bed for an unknown amount of time. On 11/21/23, it was decided to hire a full-time one-on-one caregiver due to concerns about care and supervision not being provided to R1. Based on records review, on 10/17/23 R1’s physician ordered R1 to receive hospice services due to concerns about rapid decline of R1’s health, fall risk, care and supervision concerns. Also, the physician ordered the facility staff to assist with bathing, toileting, continence, dressing, transfers, assisted daily living activities (Read the full finding— CDSS inspection report, March 4, 2024 · control 21-AS-20231128151806

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with acting Administrator Erlinda Ferris. There is an allegation that staff did not provide proper assistance to residents in care. Per reporting party, resident (R1) often becomes physically aggressive with staff resulting in staff not been able to assist with showering in the past two months. Based on LPA’s interview conducted with acting Administrator, R1 has a behavior and will be assisted with bathing “only once a month, R1 does not get a sponge bath, does not get a change of clothes for days or weeks and will attempt to leave the facility, due to their agitated behavior will run after caregivers that attempts to provide care, which is interpreted as refusal of services by the facility staff.” Per acting Administrator, a times R1 may be given a PRN due to aggressive behaviors. However, R1 is uncooperative in taking their medicRead the full finding— CDSS inspection report, November 20, 2023 · control 21-AS-20230918101730

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Executive Director Erlinda Ferris. There is an allegation that staff refused to seek medical attention for resident. It was alleged that resident R1 called reporting party around 6 am on 4/3/2023 said that they have been complaining to the staff about not feeling well, but staff came in their room and told them to be quite because R1 is crazy, so reporting party ended up having to call 911. LPA attempted to contact reporting party to gather additional information using phone number provided, but call was unable to be completed as dialed. LPA conducted confidential interviews with staff and residents in care. Staff (S1) provided LPA with a copy of R1’s daily progress notes, it was described that on 4/2/23 at approximate 10am, 911 was contacted then the police contacted the facility to ensure that R1 was fine. Although, on 4/24/Read the full finding— CDSS inspection report, June 1, 2023 · control 21-AS-20230404091216

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Marin Terrace for the purpose of opening a complaint and conducting the complaint investigation. LPA was greeted at the door by, Chef, Gustavo Alvarez. Interim Administrator, Tom Eiseman was found in the office approximately 20 minutes later. During the opening of the complaint investigation inspection, LPA toured the walk-in refridgerator and found the temperature in the walk-in refridgerator was at an appropriate temperature. However, after further inspection of the food condiments, LPA observed that the whipped cream was expired with an expiration dated for August 8, 2022 (See LIC 9099D and LIC 812-photo). Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeated deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and aRead the full finding— CDSS inspection report, January 3, 2023 · control 21-AS-20221230110423