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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 10/18/2023
Date Signed: 10/18/2023 02:15:58 PM


Document Has Been Signed on 10/18/2023 02:15 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: DATE:
10/18/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator/Executive Director, Shannon Brown, ahd Health and Wellness Director, Melanie FennTIME COMPLETED:
02:15 PM
NARRATIVE
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An Informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager (LPM) Kimberley Mota, Licensing Program Analyst (LPA), Caitlynn Felias, and Administrator/Executive Director, Shannon Brown, and Health and Wellness Director, Melanie Fenn. The purpose of the Informal meeting was to address an incident that occurred on 09/13/2023 where Resident 1 (R1) went missing during a community outing at approximately 12:45PM. R1 was found safe in a nearby neighborhood at approximately 7:45PM.

Items addressed during today’s meeting:
· Facility’s procedures regarding community outings, resident elopements and absence without leaves (AWOLs)
· Staff Training for residents with dementia and elopements
· Incident Report received by Community Care Licensing (CCL) on 10/16/2023. Incident Report received stated that Resident 2 (R2) eloped from the facility on 10/15/2023. R2 was found by local police approximately two blocks away from the facility. Facility made all notifications per regulation. Review of R2’s Physician Report and Care Plan indicated that they are unable to leave the facility unassisted (This deficiency has been cited, see LIC809D and LIC421IM, Regulation 87705(b)(2)).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**A Civil Penalty in the amount of $1,000.00 is being issued today due to a repeat violation of Regulation 87705(b)(2) within a 12-month period. (See LIC421IM).**

Exit interview conducted. Copy of report, LIC809D, LIC421IM, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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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Document Has Been Signed on 10/18/2023 02:15 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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2023
Section Cited
CCR
87705(b)(2)

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87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering...
This requirement is not met as evidenced by:
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Licensee to submit a written plan of updated procedures for elopement prevention. Licensee to submit documentation regarding delayed egress doors and to conduct an In-service training with all care staff regarding Elopement Procedures by POC due date of 10/19/2023.
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Based on documents reviewed, the Licensee did not comply with the section cited above. Resident 2 (R2) eloped from facility and was found 2 blocks away. R2’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.
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In-service training to include the following: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 10/29/2023.

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
LIC809 (FAS) - (06/04)
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