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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 02/29/2024
Date Signed: 02/29/2024 10:57:10 AM


Document Has Been Signed on 02/29/2024 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 73DATE:
02/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie FennTIME COMPLETED:
11:05 AM
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At approximately 10:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management – Incident visit and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn. The purpose of the visit is to follow up on incident report that were self-reported to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report from the facility on 02/22/2024. Report states that on 02/21/2024, Resident 1 (R1) was observed to have a stage two coccyx wound. Facility provided first aid. Facility made all appropriate notifications per regulation.

Per conversation with Administrator and Health and Wellness Nurse, R1 was observed to have the stage two wound on 02/21/2024. Per Physician communication, R1 is to be referred to Accent Care to receive an evaluation and specialist care. LPA was informed that Accent Care has already begun to oversee R1's wound care. Facility is communicating with Accent Care regarding R1's wound treatment and is documenting appropriately.

No Deficiencies Cited during visit.



Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director and Health and Wellness Director. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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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