216801686-12-29-2022-21-AS-KMOA-CN8S8G-20230119123905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 12/29/2022
Date Signed: 12/29/2022 09:35:10 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2022 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20220907101331

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:	137	CENSUS: 81	DATE:	12/29/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director, Shannon Brown RN-Melanie Fenn		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility does not have adequate staff to meet the needs of residents
Staff does not respond to resident's emergency call button in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Aldersly for the purpose of delivering complaint findings. LPA met with, Executive Director, Shannon Brown, and was granted access into the facility. Also participating during the delivery of findings were, Melanie Fenn.

During the course of the investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. There is an allegation that Staff does not respond to resident’s emergency call button in a timely manner and Facility does not have adequate staff to meet the needs of residents. A review of facility’s call button logs showed that multiple resident pendants had wait times of an hour or more before being cleared. It was also observed that the call buttons would reset and continue to alarm until they were cleared by staff. Interviews conducted stated that residents have waited for staff assistance for as long as 20 to 40 minutes or would have no staff respond at all. It was stated that some residents no longer use their pendants because they do not feel confident that someone will help them.

(Report continued on LIC 9099C)

Substantiated

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: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220907101331

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ALDERSLY	FACILITY NUMBER: 216801686
	VISIT DATE: 12/29/2022

NARRATIVE

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Staff interviews conducted stated that there have been issues with the pendant devices such as call buttons alarming when residents have not called for assistance and alarming for residents who were out of the facility, or no longer residing at the facility. Interviews revealed that sometimes staff members would forget to clear the call button after assisting a resident resulting in the button continuing its alarm until it was properly cleared. Interviews conducted indicated that the facility was aware of the devices having issues but could not determine its cause. LPA was informed that the call light system would be undergoing a system audit to address the issues observed with the call light system and defective pendants. Based on documents reviewed, observations made, and interviews conducted, the allegations that Staff do not respond to resident’s emergency call button in a timely manner and Facility does not have adequate staff to meet the needs of residents have been Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220907101331

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ALDERSLY	FACILITY NUMBER: 216801686
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/30/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements – General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…	1 2 3 4 5 6 7	Licensee to submit a self-certification statement that a plan of action will be written regarding facility staffing and call light system by POC due date of 12/30/2022. Plan of action to detail how facility will ensure there is sufficient staff
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on records reviewed and interviews conducted, facility staff were unable to respond to resident care needs and call buttons in a timely manner. Records reviewed indicated that multiple call buttons had response times of an hour or longer. Interviews stated that there was an issue with facility pendants not working properly. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14	available to respond to resident care needs in a timely manner and to include a timeline of when call light system is expected to be audited. Facility to notify CCL of any updates involving system audit progress or delays. Plan to be submitted to CCL by POC date of 01/09/2023.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

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