<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 03/09/2023
Date Signed: 03/16/2023 08:48:34 AM

Unfounded


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
03/02/2023 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20230302111949
FACILITY NAME:ALDERSLYFACILITY NUMBER:
216801686
ADMINISTRATOR:MOMO DUOAFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:137CENSUS: 82DATE:
03/09/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Executive Director, Shannon Brown, and Charge Nurse, Melanie FennTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing resident's files to resident's authorized representaive.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a complaint investigation regarding the above allegation and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn.
There is an allegation that Staff are not providing resident’s files to resident’s authorized representative. Based on records reviewed and interviews conducted, LPA observed that Resident 1 (R1) resided in the Independent Living area of the facility. Community Care Licensing (CCL) does not have jurisdiction to enforce regulations on that portion of the facility. LPA was unable to identify any deficiencies on the Assisted Living (AL) side of the facility where CCL does have jurisdiction. The allegation that staff are not providing resident’s files to resident’s authorized representative is UNFOUNDED. An allegation that is UNFOUNDED, means that the allegation was false, could not have happened and/or is without a reasonable basis.
No Deficiencies Cited during visit.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
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 1