216801686-8-10-2021-21-AS-HDBI-C62W4P-20210819165753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 08/10/2021
Date Signed: 08/10/2021 01:08:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210413081143

FACILITY NAME:	ALDERSLY		FACILITY NUMBER:	216801686
ADMINISTRATOR:	GILBERT CARRASCO		FACILITY TYPE:	741
ADDRESS:	326 MISSION AVENUE		TELEPHONE:	(415) 453-7425
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	122	CENSUS: 67	DATE:	08/10/2021
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Administrator, Preet Kaur		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff installed inappropriate alarm on resident's door.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 21-AS-20210413081143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ALDERSLY	FACILITY NUMBER: 216801686
	VISIT DATE: 08/10/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Complaint alleges that Staff installed inappropriate alarm on resident's door. Based on observation and interviews during a virtual tour conducted on April 14, 2021, LPA verified the volume of the door alarm outside of R1s room. During interviews with witnesses learned that it was disclosed that the alarm was a volume that might cause the resident not to come out of the room. Facility was made aware of this and rectified the issue right away by turning down the alarm to a level that staff members can hear without causing stress to residents. In addition, LPA verified that a camera in a common hallway which is not directed towards or is inside the resident’s room and does not infringe on the Personal Rights of the residents in care. LPA observed that the camera that was in the hallway pointed at the wall across from where the camera was situated and where no resident room was located. Camera was also inaccessible on a mobile device reflecting no audio and was only accessible on a computer inside a room close to the Administrators office.

A finding that the complaint allegation Staff installing inappropriate alarm on resident's door will be unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report continued on LIC 9099A

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210413081143

FACILITY NAME:	ALDERSLY		FACILITY NUMBER:	216801686
ADMINISTRATOR:	GILBERT CARRASCO		FACILITY TYPE:	741
ADDRESS:	326 MISSION AVENUE		TELEPHONE:	(415) 453-7425
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	122	CENSUS: 67	DATE:	08/10/2021
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Administrator, Preet Kaur		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's responsible party was not notified of resident's room modifications.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Farhaan Sarangi conducted a complaint investigation for the purpose of delivering complaint findings. LPA met with Administrator, Preet Kaur and was granted access into the facility.

LPA Sarangi initiated an investigation beginning on April 14, 2021 at approximately 09:10 AM. LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties, witnesses and conducted virtual tour of the facility on April 14, 2021 at approximately 12:30 PM. Various documents were reviewed including facility records, Care Plan, LIC 602 (Physicians Report) and Power of Attorney (POA) documentation. Resident could not be interviewed during the investigation.

Complaint alleges that Resident's responsible party was not notified of resident's room modifications. Based on a record review LPA observed documentation identifying that R1 had a Change of Condition and that the responsible party was notified on April 07, 2021 via telephone by the nurse. This was corroborated by the Responsible Party via a confidential interview that was conducted on June 07, 2021 and also documented on the Care Plan. (Report continued on LIC 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20210413081143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ALDERSLY	FACILITY NUMBER: 216801686
	VISIT DATE: 08/10/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	This agency has investigated the allegation of Resident’s responsible party not being notified of resident’s room modifications. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No citations issued this visit.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4