216801686-3-16-2023-21-AS-CFES-CPYLKU-20230316085003

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 03/09/2023
Date Signed: 03/16/2023 08:50:45 AM

Document Has Been Signed on 03/16/2023 08:50 AM - 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:	ALDERSLY		FACILITY NUMBER:	216801686
ADMINISTRATOR:	SHANNON BROWN		FACILITY TYPE:	741
ADDRESS:	326 MISSION AVENUE		TELEPHONE:	(415) 453-7425
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	137	CENSUS: 82	DATE:	03/09/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Executive Director, Shannon Brown, and Charge Nurse, Melanie Fenn		TIME COMPLETED:	03:00 PM

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At approximately 11:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management – Incidents visit and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn. The purpose of the visit is to follow up on incident reports that were self-reported to Community Care Licensing (CCL).

Incident Report #1/Death Report: CCL received an incident report from the facility on 1/10/2023. The incident occurred on 1/9/2023. The report stated that Resident 1 (R1) was found outside in the bushes by another resident. The resident notified staff who notified Emergency Personnel. R1 was transported to the hospital. Facility made appropriate notifications per regulation. On 2/7/2023, CCL received a death report for R1.

LPA, Executive Director, and Charge Nurse discussed R1. R1 resided in the Independent Living area of the facility. They were ambulatory with an assisted walking device and paid for a private caregiver. Facility has been in contact with the Marin Coroner regarding R1.

Incident Report #2: CCL received an incident report from the facility on 1/27/2023. The incident occurred on 1/27/2023. The report stated that Resident 2 (R2) was observed by staff trying to get out of bed. R2 was observed to have a skin tear on their leg. Staff applied first aid and monitored R2 appropriately. Facility made appropriate notifications per regulation.

LPA, Executive Director, and Charge Nurse discussed R2. R2 has a history of skin tears and was observed to have a change of condition and increased care needs. As of today, 3/9/2023, R2 has transitioned out of the facility’s Assisted Living and now resides in the facility’s Memory Care.

Incident Report #3/SOC-341: CCL received an incident report from the facility on 2/14/2023. The incident occurred on 2/14/2023.

Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/09/2023

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Continued from LIC809

The report stated that the Facility was informed by Resident 3 (R3’s) Responsible Party of potential financial abuse occurring between R3 and their private caregiver. Facility made appropriate notifications per regulation.

LPA, Executive Director, and Charge Nurse discussed R3. Facility has been in contact with R3’s Responsible Party and Law Enforcement. Until the investigation is complete, the private caregiver has been suspended from being at the facility. Per conversation with the Executive Director and Charge Nurse, R3’s responsible party reviewed R3’s finances and made appropriate changes. The police investigation regarding the incident is still pending.

No Deficiencies Cited during visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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