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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:17:06 PM


Document Has Been Signed on 02/07/2023 01:17 PM - 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:ALDERSLYFACILITY NUMBER:
216801686
ADMINISTRATOR:GILBERT CARRASCOFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:137CENSUS: 78DATE:
02/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive Director, Shannon Brown, and Charge Nurse, Melanie FennTIME COMPLETED:
01:30 PM
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At approximately 12:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Executive Director, Shannon Brown, and Charge Nurse, Melanie Fenn. The purpose of the visit is to follow up on a plan of correction cited on 12/29/2022 and review expectations for annual visits.

LPA Felias, Executive Director, and Charge Nurse discussed the following:
  • Incident Reports/Death Reports
  • Status Solutions Audit for Call Light System
  • Full Annual Expectations
  • Updating Staff and Resident Files as needed
  • Staff Training


No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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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