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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800977
Report Date: 06/18/2026
Date Signed: 06/19/2026 11:20:44 AM

Document Has Been Signed on 06/19/2026 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR/
DIRECTOR:		DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE BLVDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 55CENSUS: 29DATE:
06/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator, Annemarie DomizioTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a required Annual inspection and was greeted by concierge. LPA met with Business Office Director (BOD) Ravi Banwait. Administrator Annemarie Domizio arrived later. Administrator certificate # 7015132740 expires 12/19/28. Facility currently has 29 residents in care, five (5) of which are currently on hospice. Facility is full memory care with apartments on the 2nd and 3rd floors containing a total of 36 apartments.

The facility has a fire clearance approved for 55 Nonambulatory residents with magnetic locked egress doors and gates on all patios and levels, last effective date of 8/20/2019. During 7/2025 annual inspection LPA observed some resident apartment windows screwed/locked shut and some not functioning, against fire clearance safety regulations. After inspection Fire Department implemented a conditional fire clearance until 9/18/2026 at which time all windows/screens are to be fixed/replaced as per fire inspectors’ guidelines. During today’s inspection none have yet to be replaced.

At approximately 9:30am LPA and BOD toured the building and grounds & was accompanied by Administrator shortly after. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food items located in main kitchen were not stored in a safe manner and open items were not covered or closed. Items found uncovered or unsealed or both include: dried green peas & Messa, chicken, hamburger patties out on tray in kitchen, box of frozen peas, mini pies, slices of carrot cake, ice cream containers (deficiency cited, see pics & 809D).
Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977
VISIT DATE: 06/18/2026
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Continued from 809...

LPA, cook, and Admin observed bleach and other toxins stored in main kitchen next to food preparation area (deficiency cited, see pics & 809D). LPA and BOD observed unlocked kitchen cabinet under sink in 3rd Floor MC unit to contain disinfectant cleaning supplies (deficiency cited, see pics & 809D).

Laundry soaps are located in a locked closet and inaccessible to residents in care.

All bedrooms were equipped with lighting, night stand, closets, and chest of drawers by facility. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident showers (4 on each floor) had required bath mats and grab bars and or shower chairs; although, per staff, 3 showers on the 3rd floor and 1 on the 2nd floor is not working and has not been for a few years due to different issues. Facility is in the process of getting fixed per Administrator. Water temperature in sinks measured at 120.9 degrees F in room #211, 120.5 degrees F in room #203, 119.6 degrees F in room #200, 121.4 degrees F in room #311, and 121.1 degrees F in room #301, finding 6 out of 10 rooms tested not within the allowable range of 105 to 120 degrees F. (deficiency cited, see 809D). Facility has other bathrooms used by staff only.

Fire extinguishers were last inspected 9/10/25. Smoke detectors located throughout the facility are hardwired and serviced by vendor. Last date of service was 4/15/26. Deficiencies were cited and cleared per Administrator 6/18/2026. Carbon Monoxide detectors are on each floor and tested. Facility’s last quarterly disaster drill was conducted on 5/18/26. Facility has a backup generator for use during a power outage. LPA observed evacuation chairs present at top of stairwell and by back doors on 2nd & 3rd floor where stairs are on exterior.

At approximately 12:30pm LPA conducted a review of six (6) resident files. Resident (R5) does not have current physician reports on file (deficiency cited, see 809D). Resident (R6) did not have TB clearance on file (deficiency cited, see 809D). Resident (R4) does not have a pre-appraisal on file (deficiency cited, see 809D).

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977
VISIT DATE: 06/18/2026
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Continued form 809C...

At approximately 11:25am LPA, and MedTech began spot check of medication. Facility uses an electronic MAR and medication management system. Signed doctors' orders were on file. Facility utilizes e-MAR for PRNs. LPA advised to MedTech to ensure both reason for administering and outcome of administration are recorded and to provide as much detail as applicable. LPA advised that doctors' ordered must be followed per written instructions. Medication review found resident (R2) was missing 1 Trazadon per count, R3 AM Amlodipine (1 missing) Levothyroxine (3 not given), R4 Benzopril (6 additional pills). (deficiency cited, see 809D).

LPA will return at a later date to complete annual inspection. At that time LPA will issue citations for the deficiencies identified today and any identified upon return visit.

Exit interview conducted with Admin and a copy of this report given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4