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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 04/21/2023
Date Signed: 04/21/2023 01:49:37 PM


Document Has Been Signed on 04/21/2023 01:49 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:SHANNON BROWNFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:137CENSUS: 77DATE:
04/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Shannon Brown (Administrator)TIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Administrator Shannon Brown to conduct a case management visit to follow up and cite deficiencies discovered during complaint investigation.

During today’s visit, LPA is following up on a death report received at CCL on 2/7/2023. Per death report, on 1/9/23 resident (R2) who resided in the independent living section of the facility. R2 was found outside in the bushes by another resident, who notified staff and they called Emergency Personnel that transported R2 to the Hospital. R2’s responsible party were notified. However, LPA inquired with San Rafael Police Department and it was revealed that law enforcement was not contacted about the incident. LPA was informed that 911 was contacted, LPA is requesting security guard contract including frequency of round checks conducted for the month of January 2023. However, this incident needs further investigation and review prior to make a final determination.



LPA learned through records review and interviews with Health/Wellness Director that resident (R1) had two incidents of falls on 12/6/22 and 12/30/22 which were not reported to CCL within 7 days of incident. Also, death reports for R1 who passed away on 1/4/23 and R2 who passed away on 1/9/23 were not submitted to CCL until 2/7/23.

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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/21/2023 01:49 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2023
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by:
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Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, contact an outside vendor to conduct training for staff involved on reporting requirements. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date.
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Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of two incidents involving R1 after falls that occurred on 12/6/22 and 12/30/22 which poses a potential health & safety risk to residents in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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