216801686-9-9-2021-21-AS-FSAI-C6PQW7-20210909123130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 09/09/2021
Date Signed: 09/09/2021 12:32:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 81	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:54 AM
MET WITH:	Administrator, Preet Kaur		TIME COMPLETED:	12:45 PM

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	Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Aldersly for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Administrator, Preet Kaur. LPA was granted access into the facility. The facility is composed of multiple buildings for CCRC with independent living and assisted living setting licensed by Community Care Licensing on all floors. The assisted living setting is on a building in the right side of the facility. The facility also has a skilled nursing setting that is not licensed by Community Care Licensing. LPA toured the facility at 11:00 AM with Administrator, Preet Kaur; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were free from obstructions at the time of the visit. Fire Extinguisher was found to be last charged on 01/2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors, carbon monoxide, and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 07/29/2021 . There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 115.8 degrees F and 120.0 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in bathrooms while touring the facility. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA toured the kitchen area on and learned that there are provisions made for individuals/residents with special dietary needs. Facility has posted in assisted living kitchen resident’s names and their needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked room. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Facility understands that all beds should be outfitted with mattress pads as per Title 22 Regulations # 87307. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/09/2021

NARRATIVE

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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE in the office and attic. Facility is in the process of being N95 Fit tested.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Preet Kaur.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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