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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:13:37 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
10/07/2022 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20221007124556
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
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director, Shannon Brown, and Charge Nurse, Melanie FennTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Neglect/Lack of supervision resulting in resident sustaining unexplained injuries
INVESTIGATION FINDINGS:
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At approximately 10:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation 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 of Neglect/Lack of supervision resulting in resident sustaining unexplained injuries. Based on information provided to LPA, the unexplained injury was described as a “gash” on Resident 1’s (R1) scalp and bruising on their cheek. Review of Facility documents during the alleged timeframe of injury did not show any written documentation of a gash being observed on R1’s scalp. Review of R1’s Physician Report dated 10/04/2018, indicated that R1 does not have dementia and can communicate their needs. Based resident interviews conducted, LPA received inconsistent information regarding how facility staff treat residents.
Continued LIC9099C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20221007124556
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

However, interview conducted with R1 stated that the staff are wonderful and help them with their care needs. R1 stated that they do not know where the bruises came from and stated they just happen. Staff interviews conducted indicated that there have been no observations made where staff treated residents roughly. Based on Record Review, observations made, and inconsistent information provided during interviews conducted, the LPA is unable to determine if the facility neglected or had a lack of supervision in resident's care resulting in unexplained injuries. 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 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2