216801686-2-29-2024-21-AS-VBEI-D33Q2G-20240305104703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 02/29/2024
Date Signed: 02/29/2024 10:56:06 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
11/15/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231115131419

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: 73	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie Fenn		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to meet resident's care needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie Fenn.

During the course of the investigation, LPA Felias requested and reviewed documents, conducted interviews, and made observations. There is an allegation that Facility failed to meet resident's care needs. Reporting Party alleges that facility did not meet Resident 1’s (R1’s) care needs by not showering R1, not providing incontinence care to R1, and not giving R1 their suppository medication. Reporting Party also alleges that the lack of care resulted in R1 contracting sepsis from a urinary tract infection resulting in hospitalization. LPA conducted interviews with involved individuals. Per interviews, LPA was informed that a care conference meeting was conducted with the facility to address concerns regarding R1’s care.
Continued LIC9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 21-AS-20231115131419

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ALDERSLY	FACILITY NUMBER: 216801686
	VISIT DATE: 02/29/2024

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
26
27
28
29
30
31
32

Continued from LIC809

LPA was also informed that facility performed an enema for R1 after a suppository was requested. Supporting documents related to R1’s care was requested but per interview, were no longer available for LPA to review. LPA was unable to interview staff members that provided care to R1 during the time frame of January 2022 to June 2022, because the staff members were no longer employed at the facility or were unable to recall details related to R1.

Review of R1’s Physician Report dated 12/28/2021 stated that R1 had a diagnosis of dementia and chronic kidney disease. Review of R1’s Functional Capability Assessment dated 12/31/2021, stated that R1 had a history of UTI and required total assistance with Activities of Daily Living (ADLs). Review of R1’s Communication Log stated that on 06/04/2022, R1 was assessed by facility staff where it was determined that R1 had a change in condition. Facility contacted Emergency Personnel to have R1 evaluated. LPA did not observe any other notes regarding R1’s care prior to this incident. R1’s Physician’s Orders dated 03/21/2022 indicated that R1 was able to receive a suppository, as needed, if their Milk of Magnesia was ineffective. There was no documentation to indicate that R1 needed a suppository and if it was given.

Due to lack of evidence and available documentation, LPA is unable to determine if a violation of Title 22 Regulations occurred, therefore this allegation is Unsubstantiated.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 2