216801686-4-5-2022-21-AS-HDBI-CD7VU4-20220405164407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 04/05/2022
Date Signed: 04/05/2022 01:04:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/04/2022 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20220104105304

FACILITY NAME:	ALDERSLY		FACILITY NUMBER:	216801686
ADMINISTRATOR:	GILBERT CARRASCO		FACILITY TYPE:	741
ADDRESS:	326 MISSION AVENUE		TELEPHONE:	(415) 453-7425
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	137	CENSUS: 35	DATE:	04/05/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Staff Member, Momo Dua		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident's fell multiple times while in care
Resident's sustained minor injuries while in care
Unqualified staff providing care to resident's
Staff are not providing resident's with adequate laundry service
Staff are not meeting resident's hygiene needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi conducted a complaint investigation for the purpose of delivering complaint findings. LPA met with Staff Member, Momo Dua and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses. LPA conducted a tour of the facility on February 24, 2022, March 02, 2022 and April 5, 2022.

Complaint alleges that Resident's fall multiple times while in care and sustain minor injuries while in care. Based on interviews, LPA learned that R1 sustained a fall and pressed the pendent multiple times. However, dates and times could not be recalled. LPA performed a review of the Pendent Call Log for 60 days and found that on February 12, 2022, R1 did fall and waited approximately 11 minutes to be retrieved from the floor.

Report continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220104105304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/05/2022

NARRATIVE

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LPA learned that the facility tries to retrieve residents from the floor in a timely manner and as quickly as possible. During these falls, LPA learned that minor injuries were disclosed to appropriate parties but was not reported to Community Care Licensing Division (See LIC 809).

Complaint alleges that Unqualified staff provides care to residents. Based on observations of facility training records LPA learned that the facility does onboard training of staff members. LPA confirmed via a review of the LIC 500 and a review of current training records that a newly hired Medication Technician that was hired in late 2021 and is currently going through the on boarding training hours at the facility. During the tours and observations of the facility dated on February 24, 2022, March 02, 2022 and April 5, 2022, LPA observed sufficient staff members at the facility. LPA also observed the facility to be clean and exits free from obstruction. During the tour on April 5, 2022, LPA tested the call light in R1's room, and found that staff responded within an appropriate time frame.

Complaint alleges that staff are not providing resident's with adequate laundry service and are not meeting resident’s hygiene needs. LPA interviewed identified staff members, various outside parties, Resident #1 (R1) and Resident #2 (R2). Based on the interviews that were conducted and the information received, there was inconsistent information and no concerns with laundry or resident’s hygienic needs.

A finding that the complaint allegations of, Resident's fall multiple times while in care, Resident's sustained minor injuries while in care, Unqualified staff providing care to resident's, staff are not providing resident's with adequate laundry service and are not meeting resident’s hygiene needs are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Staff Member, Momo Dua.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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