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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 08/31/2026
Date Signed: 08/31/2026 04:02:39 PM

Substantiated


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
05/29/2026 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20260529141335
FACILITY NAME:ALDERSLYFACILITY NUMBER:
216801686
ADMINISTRATOR:MIKE SHARKEYFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:172CENSUS: 94DATE:
08/31/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Business Office Manager, Eliana Lopez, and Health and Wellness Director, Melanie Fenn TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Personal Rights - Facility Did Not Allow Resident's Family to Visit
INVESTIGATION FINDINGS:
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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Business Office Manager, Eliana Lopez (BOM). Heath and Wellness Director (HWD), Melanie Fenn, arrived during visit at approximately 9:50AM.

During the course of the investigation, the Department reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Personal Rights - Facility did not allow resident's family to visit." Complaint alleged that facility staff did not allow Visitor 1 (V1) to enter the facility to see Resident 1 (R1) in March 2026.

Interview conducted with HWD revealed that R1 had a restraining order in place against V1 but were unsure if the restraining order had expired. Per HWD, V1 was not allowed to visit R1 due to financial concerns
Continued on LIC90999
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
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 7
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
05/29/2026 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20260529141335

FACILITY NAME:ALDERSLYFACILITY NUMBER:
216801686
ADMINISTRATOR:MIKE SHARKEYFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE:CAZIP CODE:
94901
CAPACITY:172CENSUS: 94DATE:
08/31/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Business Office Manager, Eliana Lopez, and Health and Wellness Director, Melanie FennTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Fire Clearance - No Evacuation Chairs at Stairwells
Facility Not Meeting Resident's Care Needs
Staff Not Properly Trained on Transferring Residents
Neglect/Lack of Supervision
INVESTIGATION FINDINGS:
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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived uannounced to deliver findings regarding a complaint investigtion regarding the above allegations and met with Business Office Manager (BOM), Eliana Lopez. Health and Wellness Director (HWD), Melanie Fenn, arrived during visit at approximately 9:50AM.

During the course of the investigation, the Department reviewed documents, conducted interviews, and made observations. The following allegations were investigated, "Fire Clearance - no evacuation chairs at stairwells, Facility not meeting resident's care needs, Staff not properly trained on transferring residents, and Neglect/lack of supervision."

"Fire Clearance - no evacuation chairs at stairwells" - Complaint alleged that the facility's expansion building (Marselisborg building) did not have evacuation chairs at the stairwells in Summer 2025. Complaint did not
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 21-AS-20260529141335
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: 08/31/2026
NARRATIVE
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Continued from LIC9099A

identify the month that this observation was made.

Review of Community Care Licensing (CCL) report, dated 08/20/2025, stated that the facility had a visit conducted by the Department to address the facility's expansion of their Marselisborg building and address the facility's change of capacity. Per report, the visit was to see if the facility's expansion was ready to be licensed by the Department. During visit conducted on 08/20/2025, the facility's new license was granted. On 10/03/2025 and 10/21/2025, facility had their annual inspection visit conducted. Review of inspection notes showed that the facility had evacuation chairs at each stairwell at the time of inspection. During visit conducted on 06/04/2026, it was observed that that there were two evacuation chairs located in the Assisted Living building, two evacuation chairs located in the expansion building/Marselisborg building, and one evacuation chair located in the Extended Care building.

Based on record review and observations made, this allegation is Unsubstantiated.

"Facility not meeting resident's care needs" - Complaint alleged that R1 had a fall in February 2026 and facility staff did not clean R1's bathroom and left fecal matter on the bathroom floor after their fall. Complaint also alleged that R1's meal trays were not removed from their room for up to six hours when they were in Extended Care, and that R1 never received treatment from their breathing machine while in Extended Care.

Review of R1's progress notes showed that R1 was in Extended Care from 02/11/2026 to 04/20/2026, and moved to Assisted Living on 07/28/2026.

An interview with R1 was conducted. Per R1, they resided as an Independent Living resident until the beginning of August 2026 when they moved to the facility's Assisted Living. During the interview, R1 stated that the facility staff made them feel special and and felt that their needs were being met. Per R1, when they would have an accident in Independent Living, they would call for assistance and facility staff would help with cleaning right away. When asked if the facility staff took a long time to remove food trays from their room, R1 stated that they felt that facility staff did a good job.

An interview with R1's responsible party was conducted. Per responsible party, the facility goes above and beyond for R1 to make sure that they are okay and well taken care of. Responsible party also stated that they have no concerns with the services provided, and said that the staff ensure that R1's room is clean and that they are informed of any incidents that have occurred with R1.
Continued on LIC9099C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 21-AS-20260529141335
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: 08/31/2026
NARRATIVE
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Continued from LIC9099C

Review of R1's medication list showed that R1 had the following medications prescribed for help with breathing.
  • Wixela Inhub 250-50 MCG BLST W/DEV: give 250-50MCG/ACT aerosol powder breath activated by inhalation two times per day every day. Inhale 1 puff by mouth twice daily.
  • Albuterol Sulfate 2.5MG/3ML vial: give (2.5MG/3ML) vial Nebulization Solution by Inhalation as needed. Use 1 Vial via nebulizer every six hours as needed for wheezing/shortness of breath
  • Albuterol Sulfate HFA 90MCG HFA AER AD: give (108/90 base) MCG/ACT Aerosol Solution by Inhalation as needed every 4 hours. Inhale 2 puffs into the lungs every 4 hours as needed for cough and wheezing.

Interview with HWD stated that R1 does not have a breathing machine and used inhalers to help with their breathing.

Interview with R1 confirmed that they do not use a breathing machine and use inhalers to help with their breathing. Per R1, they have a PRN or "as needed" inhaler prescribed to be used when they need it. R1 revealed that they do not tell the facility staff when they administer the "as needed" inhaler since they keep it in their walker. R1 also stated that they were not aware they had a routine inhaler prescribed for twice a day and stated the facility staff have not been administering this routine medication to them.



Review of R1's electronic medication administration record (EMAR) for February, March, and April 2026, showed that R1's routine inhaler was administered or refused by R1.

Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated.

"Staff Not Properly Trained on Transferring Residents" - Complaint alleged that the facility staff did not know how to transfer R1 to and from the toilet. Interview with R1 stated that they felt safe when facility staff were helping or transferring them. Review of facility records showed that on 10/08/2025, the facility conducted a training on fall prevention and transferring for Assisted Living, Memory Care, and Extended Care facility staff.

Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated.

Continued on LIC9099C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20260529141335
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: 08/31/2026
NARRATIVE
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Continued from LIC9099C

"Neglect/Lack of Supervision" - Complaint alleged that R1 had a fall in February 2026 and that facility staff did not check on them after their fall. Interview with R1 stated that that they had a fall while they were in Independent Living and the staff came to help them. R1 stated that after their fall, facility staff came to check on them, and asked if they had any pain or if they were okay.

Review of R1's Progress Notes showed that on 01/22/2026, R1 had a fall. Per notes, R1 denied hitting their head and other extremities. R1 also denied being in pain and declined to have additional medical attention. Progress notes showed that R1 was checked on in the following days.

Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated.

A finding that a complaint allegation 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.

Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20260529141335
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: 08/31/2026
NARRATIVE
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Continued from LIC9099

raised by R1's responsible party.

Interview conducted with Resident Care Manager (RCM), revealed that on 06/03/2026, V1 was at the facility. RCM was unsure if V1 was escorted off the property or if they chose to leave the property on their own once it was determined they were on-site. Per RCM, they did not know why V1 was not allowed at the facility, but had been informed that V1 was not allowed to visit with R1.

A review of R1's file was conducted. R1's file showed that on 07/14/2023, a restraining order against V1 was put in place and had an expiration date of 07/13/2024. Further review showed that R1's file did not have a current restraining order in place to prohibit V1 from visiting with R1.

Based on record review, interviews conducted, and observations made, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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.

Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20260529141335
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2026
Section Cited
CCR
87468.1(a)(11)
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87468.1 Personal Rights of Residents in All Facilities: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors...permitted to visit privately during reasonable hours and without prior notice...
This requirement was not met as evidenced
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Licensee to conduct an in-service training with all staff members on the topic of resident rights, visitation, and when a visitor would be restricted or prohibited from the facility. Training to include: Supporting Documents, Date of Training, Topic, Staff Names, Staff Roles, and Staff Signatures.
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by: Based on record review and interviews conducted, Licensee did not comply with the section cited above and did not allow V1 to visit with R1. This is a potential health, safety, and/or personal rights risk to residents in care.
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Proof of training and supporting documents to be submitted to CCL by POC due date of 09/11/2026.
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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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7