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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 02/10/2022
Date Signed: 02/10/2022 01:19:49 PM

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:GILBERT CARRASCOFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:122CENSUS: 78DATE:
02/10/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Gilbert CarrascoTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Aldersly unannounced for the purpose of reviewing the physical plant for a capacity increase. LPA was greeted by Administrator, Gilbert Carrasco, and was granted access into the facility.

LPA toured the facility, including the area involved in the capacity increase. LPA observed rooms that appear to be able to accommodate 15 residents. LPA observed 5 private bedrooms and 5 shared bedrooms. The 5 shared bedrooms will have 2 residents per room. Rooms are furnished per regulation. LPA has received fire safety inspection approving the increase. LPA observed two fire extinguishers that were dated for January 2022. Exits were free from obstruction in rooms. Licensee is requesting capacity increase from 122 to 137. New construction was completed on December 2021. During the Case Management inspection, LPA obtained a new facility sketch designating new facility rooms.

No deficiencies were observed or cited in the areas toured by LPA. Exit interview was conducted and a copy of this report was signed and emailed to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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