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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 07/07/2022
Date Signed: 07/07/2022 11:33:52 AM


Document Has Been Signed on 07/07/2022 11:33 AM - 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: 82DATE:
07/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Executive Director, Shannon BrownTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Aldersly for the purpose of conducting a Case Management- Deficiencies inspection. LPA was greeted at the door by Executive Director, Shannon Brown, and was granted access into the facility.

During the subsequent complaint investigation inspection dated for July 7, 2022, LPA toured the facility at 09:15 AM with the Executive Director and observed Resident #1's (R1's) room being clean, but the closet where the resident stores clothing had a trash bag tied (See LIC 812-Picture taken) around preventing the resident from accessing clothes which presents a Personal Rights issue. Executive Director removed the trash bag.

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: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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Document Has Been Signed on 07/07/2022 11:33 AM - 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: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited

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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:
(3) To be free from punishment, humiliation, intimidation, abuse,
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or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement was not met as evidenced by:
During a tour of the facility, LPA observed a trash bag on R1's closet that prevents R1 from obtaining clothing to wear. This presents an immediate health, safety and personal rights risk to residents in care.
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Licensee shall train staff on Personal Rights and provide proof of training along with a sign-in sheet by July 12, 2022.

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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: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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