216801686-9-26-2023-21-AS-CFES-CW2TPV-20230926145457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 09/26/2023
Date Signed: 09/26/2023 02:55:07 PM

Document Has Been Signed on 09/26/2023 02:55 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:	ALDERSLY		FACILITY NUMBER:	216801686
ADMINISTRATOR:	SHANNON BROWN		FACILITY TYPE:	741
ADDRESS:	326 MISSION AVENUE		TELEPHONE:	(415) 453-7425
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	137	CENSUS: 71	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director/Administrator, Shannon Brown		TIME COMPLETED:	03:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 10:15AM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to conduct a 1 Year Required Visit, and met with Executive Director/Administrator, Shannon Brown. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs were informed that there were 34 residents in Assisted Living and Memory Care with 37 Independent Living residents for a total of 71 residents in care. LPAs were also informed that there were 21 staff members on-site. At approximately 10:30AM, LPAs reviewed the Facility's Staff Roster with Administrator and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:00AM, LPAs conducted a walk-though of the facility with Administrator and observed the following: Facility consists of multiple buildings for Assisted Living and Memory Care. Facility has an Extended Care unit which is a separate wing for Older Adults that require a higher level of care. Facility also has independent living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 8 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected January 2023. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected November 2022 and January 2023. Facility's last fire drill was conducted on July 2023. At approximately 12:45PM, LPAs reviewed a sample size of 3 resident files. Resident Files were all found to be well organized, thorough and contained the required documentation. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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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
	VISIT DATE: 09/26/2023

NARRATIVE

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Continued from LIC809

LPAs also followed up on a self-reported incident that was submitted to Community Care Licensing (CCL).

incident Report 1: On 9/13/2023, CCL was verbally informed that the facility was searching for Resident 1 (R1) who had disappeared during a community outing to the local zoo. CCL received an update that evening stating that R1 had been located and was safe. Facility submitted an incident report on 09/15/2023 regarding the incident and made all appropriate notifications per regulation.

LPAs discussed R1 with Executive Director, and reviewed documents. Per conversation with Executive Director, R1 was apart of a community outing to the zoo that consisted of 3 staff members and 5 residents. At approximately 12:30PM, facility staff took R1 and 3 other residents to the bathroom. Facility staff then provided the residents with lunch. At approximately 1:30PM, facility staff observed that R1 was no longer with the group when they were boarding the bus. Facility staff contacted zoo personnel and police to review security footage. Facility staff and police observed that R1 exited the zoo premises at approximately 12:45PM. At approximately 3:00PM, facility staff notified Executive Director and Health and Wellness Director of the situation who headed to the zoo's location to assist in the search. At approximately 7:45PM, R1 was found safe and unharmed in a nearby neighborhood. Since returning to the facility, R1 has been observed to be at their baseline. Facility conducted an inservice training reviewing dementia elopements and AWOLs. Facility has also implemented new procedures regarding community outings. Per review of R1's Physician's Report, they are unable to leave the facility unassisted or without staff supervision (This deficiency has been cited, see LIC809D, 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.

Facility provided LPAs with In-service training materials and documentation. Deficiency cited today for Regulation 87705(b)(2) has been cleared during today's visit.

**An informal meeting has been scheduled for October 18th, 2023, between the Facility and the Department.

LPAs unable to complete Annual visit. Annual Continuation visit to be conducted at a later date.

Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 02:55 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: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(b)(2)

87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on File Review and Observations made, the Licensee did not comply with the section cited above. Licensee reported R1 to be missing during a community outing where R1 was not found until approximately 7 hours later. Review of R1’s Physician Report indicates that they have a diagnosis of dementia. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	Licensee to conduct an In-service training with all care staff regarding Elopement/Missing Resident Procedures. Licensee to update and implement new procedures regarding community outings. 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 09/27/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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