Facility Evaluation Report, 10/30/2025 — Windchime of Marin, Kentfield CA

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.

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.