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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 04/05/2022
Date Signed: 04/05/2022 01:03:53 PM


Document Has Been Signed on 04/05/2022 01:03 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:GILBERT CARRASCOFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:137CENSUS: 35DATE:
04/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Staff Member, Momo DuaTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi conducted a Case Management-Deficiencies inspection. LPA met with Staff Member, Momo Dua and was granted access into the facility.

During the course of the complaint investigation dated for January 4, 2022, LPA learned that R1 did sustain a fall that was unreported to licensing. In addition, incidents were not documented on an LIC 624/Unusual Incident Reports. (See LIC 809D).

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/05/2022 01:03 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: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2022
Section Cited

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87211 Reporting Requirements:

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.

(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

(C) The use of an Automated External Defibrillator.

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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This requirement was not met evidenced by:

Based on interviews with facility staff, and research of incident reports submitted to CCL, facility did not properly report an incident to the CCL as required by Title 22 regulation. This poses a potential health, safety or personal rights risk to persons in care.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2