216801686-10-15-2024-21-AS-CFES-DA3TPU-20241015145454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:54:59 PM

Document Has Been Signed on 10/15/2024 02:54 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
SANTA ROSA RO, 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: 63	DATE:	10/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie Fenn		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 10:20AM, Licensing Program Analysts (LPA) Felias arrived unannounced to conduct a 1 Year Required Visit, and met with Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie Fenn. 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, LPA was informed that there were 35 residents in Assisted Living and Memory Care with 28 Independent Living residents for a total of 63 residents in care. LPA was also informed that there were 26 staff members on-site. At approximately 10:45AM, LPA reviewed the Facility's Staff Roster with Health and Wellness Nurse and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:30AM, LPA conducted a walk-though of the facility with Health and Wellness Nurse 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 Assisted Living residents 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 2024. 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 January and August 2024. Facility's last emergency/disaster drill was conducted September 2024. LPA followed up on incident reports that were self-submitted to Community Care Licensing (CCL). Continued on LIC809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/15/2024

NARRATIVE

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Continued from LIC809

Incident Report 1: CCL received an incident report from the facility on 05/03/2024. Report states that on 05/02/2024, Resident 1 (R1) was found outside on facility grounds by the Assisted Living building. Facility made all appropriate notifications per regulation. Review of R1's physician's report and care plan indicates that they are unable to leave unassisted but they do not have a dementia diagnosis.

Incident Report 2: CCL received an incident report from facility on 06/19/2024. Report states that on 06/19/2024, Resident 2 (R2) was found on the floor. R2 was not observed to have any visible injury. Facility staff observed that R2 seemed to have had alcohol and found wine in R2's room. Facility identified that the wine was brought in by R2's family. Facility made all appropriate notifications per regulation. Review of R2's physician report indicates that they have a diagnosis of mild cognitive impairment.

Incident Report 3: CCL received an incident report from the facility on 08/26/2024. Report states that on 08/26/2024, Resident 3 (R3) was found outside across the street. Per report, facility alarm system and R3's wander bracelet was operational and functional during incident. Facility identified that the garden exit was inoperable and needed a new lock. Facility had maintenance examine and secure the identified exit. Facility made all appropriate notifications per regulation. Review of R3's physician's report and care plan indicates they are unable to leave unassisted and has a dementia diagnosis (deficiency cited, see LIC809D and LIC421IM, Regulation 87705(b)(2)).

At approximately 1:10PM, LPA reviewed resident files. Resident Files were all found to be well organized, thorough and contained the required documentation.

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).**

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

Exit interview conducted. Copy of report, LIC809D, LIC421IM (civil penalty), LIC811 (Confidential Names), Plan of Corrections Letter, and Appeal Rights discussed and provided to Health and Wellness Nurse. 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: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/15/2024 02:54 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ALDERSLY	FACILITY NUMBER: 216801686
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

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 shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the section cited above. Resident 3 eloped from facility. R3's Physician Reports state they are unable to leave without assistance and has a diagnosis of dementia. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 10/16/2024
	Plan of Correction
1 2 3 4	Licensee submitted proof of all staff training conducted on 08/27/2024 09/04/2024. Licensee also submitted proof of service, showing that exit door where R3 eloped from was inspected and fixed accordingly. Deficiency cleared during visit, and Plan of Corrections Letter provided.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

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