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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 04/21/2023
Date Signed: 04/21/2023 01:13:25 PM

Substantiated


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
01/26/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230126084215
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: 77DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Shannon Brown (Administrator)TIME COMPLETED:
01:28 PM
ALLEGATION(S):
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- Staff did not follow resident’s feeding plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Administrator Shannon Brown to deliver findings regarding the complaint allegation above.
Regarding allegation Staff did not follow resident’s feeding plan. Per Reporting Party, on 12/29/2022 it was noticed that there was a full food tray wrapped up sitting next to resident (R1) who had difficulty swallowing and was on a feeding plan where they were to be given soft or liquid foods because R1 had difficulty swallowing and was supposed to be provided assistance with eating. Also, Reporting Party noticed that there was a care plan taped over R1's bed dated 11/10/22, with a different resident’s name. Based on confidential interviews conducted with facility staff on 4/6/23, it was revealed that their normal meal process is to provide residents with their meal tray that has their name on it, then they will leave them for residents to eat it and staff will return about an hour later to remove the tray. Per staff, R1 had private caregivers that helped feeding R1. However, based on confidential interviews conducted with private caregivers, feeding R1 was not their duty to perform because they were hired for companion only. Also, based on records review of hospice care plan dated 12/25/22, R1 have a regular diet plan on file, but R1 was fully dependent, required to get assistance with feeding due to them were unable to feed self and must be assisted or supervised throughout their meals. Therefore, the facility staff did not follow resident’s hospice care plan dated 12/25/2022 about resident’s feeding care needs. The preponderance of evidence standard has been met; therefore, the above allegation of resident’s care needs is not being met is found to be SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20230126084215
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2023
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements: (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement has not been met as evidence by:
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Administrator agrees to immediately review resident’s files to ensure modified diets including feeding plan are provided per physician's order. Administrator will submit a written plan stating how the facility will ensure modified diets will be specifically followed to CCL by POC due date.

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Based on LPA’s records review and interviews with facility staff, the facility did not ensure that staff was assisting resident (R1) with their modified diet care plan as prescribed by their Physician. This poses an immediate health & safety risk to the 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/26/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230126084215

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: 77DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Shannon Brown (Administrator)TIME COMPLETED:
01:28 PM
ALLEGATION(S):
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- Staff did not adequately supervise resident.
- Appropriate measures were not put into place for resident who was a fall risk.
- Staff did not properly dispose of food.
- Staff did not administer medication(s) to resident according to instructions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Administrator Shannon Brown to deliver findings regarding the complaint allegation above.
Regarding the allegation of staff did not adequately supervise resident. Per Reporting Party, around 12/27/22 or 12/28/22, they were unable to find any staff available in the unit or all over the facility. Sometimes, only one staff have been observed for all 3 areas of the facility (Independent living, memory care and extended care unit), and there were concerns raised about the lack of staff. Based on records review of facility staff schedules for the month of December 2022, LIC500 Personnel Report and call light system records for those dates, did not indicate that facility was short staff or late responding to resident’s calls during December 27th and 28th. However, confidential interviews conducted by LPA with private caregivers provided conflicting information that the facility was usually observed under staff for this period of time and there was hard to find a staff around that could help residents when needed, but there were noticed an improvement after there was a management change. A finding that the complaint allegation staff did not adequately supervise resident is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continues on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20230126084215
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: 04/21/2023
NARRATIVE
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Continued from LIC9099A...Regarding the allegation of appropriate measures were not put into place for resident who was a fall risk. Per Reporting Party, R1 was found on the floor at least two different occasions by private caregivers after R1 had slid out of the bed, their head and shoulders on a mat and the rest of their body on the cold floor with no injuries reported. Staff were unaware that R1 had fallen because they were not checking on R1 as they should have due to R1 was a fall risk. Per Reporting Party, R1 had a fall risk bracelet on their arm, but at some point, somebody at the facility took that bracelet off and it was placed on a table. Staff had lowered R1’s bed the lowest that it could go to the floor, and mats were placed around R1’s bed to address R1's fall risk. Based on records review of facility communication log dated 12/26/22 at 5:16am and 12/30/22 at 8:29pm confirmed that R1 had an un-witnessed fall. On 12/26/22 at 5:16am, R1 was found by facility staff lying on their back on the floor next to their bed, but denies hitting their head, facility conducted assessment of the resident, no injuries or skin discoloration were noted, facility notified R1’s responsible party and hospice about the incidents. Also, bed was set to the lowest position and floor pads were placed. On 12/30/22 at 8:29pm, R1 was found by facility staff facing up lying on the floor on top of their pad next to their bed. R1 was assessed, no injuries were noted and was assisted back to bed by 3 facility staff, facility notified R1’s responsible party and hospice about the incidents. Per incident report, both incidents contributing factors were R1’s balance impairment, poor safety practices and history of falls. Per hospice records obtained dated 12/25/22, R1 had an anxiety and/or agitation problem that a goal was set to minimize them with medication regimen in place to prevent fall risk while agitated. Also, R1 was assessed as a fall risk person and both incidents were noted in hospice daily care notes. Facility staff was instructed to monitor R1, safety checks, bed safety. However, LPA reviewed incident and death report logs for resident (R1) who passed away on 1/4/23 which were not reported to CCL within 7 days of incident. This deficiency will be addressed in a case management for reporting requirements. During confidential interviews conducted with staff that works in the Health and Extended Care Center (Kronborg), upon arrival to this area, Wellness Director removes any fall risk bracelet from resident’s arms because all of them are considered fall risk due to their mobility limitations, and staff is set to conduct round checks every two hours and if any resident need help sooner, residents will pull their call light system and staff will respond to their call within minutes. LPA obtained call light system response for both incidents that confirmed that R1 was assisted within minutes after having falls. A finding that the complaint allegation appropriate measures were not put into place for resident who was a fall risk is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continue on LIC9099C...
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230126084215
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: 04/21/2023
NARRATIVE
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Continued from LIC9099C...There is an allegation that staff did not properly dispose of food. Per Reporting Party, on 12/29/2022 it was noticed that there was a full food tray wrapped up sitting next to R1. On 12/30/2022 the same plate of food was still in resident's room which posed a safety hazard since the food was probably spoiled by then. Based on records review of facility communication log dated 12/29/22 at 8:24pm R1 was observed asleep most of the shift, refused dinner, staff offered fluids, but only took sips from toothaches. According to facility Wellness Director, there is a chance that this incident could have happen because the staff are instructed to leave meal tray in resident’s rooms, then the facility staff will return to remove the trays in about an hour later, but if residents have visitors they won’t interrupt them and will come back later. Also, LPA conducted confidential interviews with private caregivers who were not able to provide any supporting information to determine if the incident could have happened at a certain date. Due to conflicting information obtained by LPA is unable to determine that the alleged violation had occurred. A finding that the complaint allegation Staff did not properly dispose of food is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation of staff did not administer medication(s) to resident according to instructions. Per Reporting Party, Hospice had written orders for the staff to give resident morphine when needed, but private caregivers noticed that facility staff were not giving R1 their morphine, when inquired with staff about it staff said no. Hospice then changed the morphine order from a “PRN” to “Q4” (given every 4 hours). Private Caregivers discovered that staff were not adhering to that order either. During confidential interviews with staff and private caregivers, it was confirmed that facility caregivers don’t have direct access to Morphine, only facility Med-techs so morphine was an issue because staff either did not have access to the computer to place orders or to administer this medication to residents. Although, facility communication log and Centrally Stored Medication and Destruction (CSMD) log all doses of medications were listed on the facility medication records to have been dispensed as ordered by the resident's Physician. Also, hospice records obtained dated 12/25/22 confirmed that there were no issues with medication administration, but a couple times R1 refused medications and there was an adjustment to this medication on 12/29/22 due to potential medication-related problems, including adverse effects, drug reactions and drug therapy currently associated with laboratory monitoring, as well as impact of disease state and the patient’s perception of side effects. On 12/30/22 there was a situation where hospice received a call from R1’s responsible party reporting that med-tech could not provide them with an answer to confirm that R1 was getting morphine every 4 hours for pain management. However, hospice called facility and spoke with same med-tech, who stated correct understanding of R1’s medication order and stated times as follow for that day: 6:15am, 10:15am, they will be given at 2:15pm and ongoing every 4 hours). LPA has determined and confirmed that although caregivers did not access to morphine medications, Med-technicians will have access, they will give R1 their prescribed medication as ordered by their Physician, and there was no indication that any dosage was missed or not administered properly by facility staff. A finding that the complaint allegations “staff did not administer medication(s) to resident according to instructions” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

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
LIC9099 (FAS) - (06/04)
Page: 5 of 5