216801686-2-7-2023-21-AS-KMOA-CP525M-20230216160547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:14:52 PM

Unsubstantiated

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
10/25/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20221025151918

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: 78	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Executive Director, Shannon Brown, and Charge Nurse, Melanie Fenn		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff do not provide enough liquids to resident in care
Staff did not report resident's incident to resident's authorized representative

INVESTIGATION FINDINGS:

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At approximately 11:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for the Complaint Investigation regarding the above allegations and met with Executive Director, Shannon Brown, and Charge Nurse, 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 do not provide enough liquids to resident in care. Interview conducted with Resident 1 (R1) stated that facility offers snacks and drinks to them. Other resident interviews conducted stated that staff offer drinks frequently. During visit conducted 2/7/2023, LPA observed a sign showing that staff offer snacks and drinks every day at 3:30PM. Based on observations made and interviews conducted, the LPA is unable to determine if staff do not provide enough liquids to resident in care. Therefore, this allegation is Unsubstantiated.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221025151918

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: 02/07/2023

NARRATIVE

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Continued from LIC9099

There is an allegation that staff did not report resident’s incident to resident’s authorized representative. Based on interviews conducted, LPA received inconsistent information. Staff interview conducted indicated that the incident involving R1 occurred on the same day that R1’s authorized representative visited the facility. The staff member, authorized representative, and a Pine Parks Representative discussed the incident involving R1. LPA was unable to conduct an interview with the Pine Parks Representative. Multiple attempts were made to obtain their contact information were unsuccessful. Based on inconsistent information provided during interviews conducted, the LPA is unable to determine if staff did not report resident’s incident to resident’s authorized representative. Therefore, this allegation is Unsubstantiated.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report, and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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