216801686-10-3-2022-21-AS-HDBI-CJX2ZX-20221005175105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801686
Report Date: 10/03/2022
Date Signed: 10/03/2022 10:11:17 AM

Unsubstantiated

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
06/20/2022 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20220620085447

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: 84	DATE:	10/03/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Executive Director, Shannon Brown		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident fell resulting in injuries to the face
Lack of cleanliness of the facility
Lack of staffing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Aldersly for the purpose of delivering complaint findings. LPA was greeted at the door by Executive Director, Shannon Brown, 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 tours of the facility on June 22, 2022, July 7, 2022, September 12, 2022 and September 27, 2022.

Complaint alleges that Resident fell resulting in injuries to the face. Based on interviews, LPA could not determine the date or time of the unwitnessed fall due to insufficient information regarding the fall itself. In addition, LPA reviewed the fall procedures for the facility and found that the facility followed their own fall procedure plan as it relates to unwitnessed fall. (Report continued on LIC 9099C)

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: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

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-20220620085447

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: 10/03/2022

NARRATIVE

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Complaint alleges lack of cleanliness of the facility. LPA toured the facility on June 22, 2022, July 7, 2022, September 12, 2022 and September 27, 2022 and found that on all those tours of the facility, facility was found to be clean and at a comfortable temperature. During the initial tour on June 22, 2022, LPA did observe a stain on R1’s carpet that was in the process of being cleaned. However, during subsequent tours conducted on said dates, LPA did not observe the same stain on R1’s floor during subsequent tours of the facility as the carpet was observed to be cleaned. Based on interviews with witnesses, LPA learned that there are no concerns with the physical plant itself.

Complaint alleges lack of staffing. LPA toured the facility on June 22, 2022, July 7, 2022, September 12, 2022 and September 27, 2022 and found that on all those tours of the facility, the facility was observed to be staffed. During interviews with staff, residents and witnesses, LPA received inconsistent statements regarding the staffing allegation. LPA reviewed the call bell log and could not find any evidence to suggest that the facility was understaffed. In addition, during a review of the facility records, LPA could not prove or disprove that the facility lacked staffing.

A finding that the complaint allegations of, Resident fell resulting in injuries to the face, lack of cleanliness of the facility and lack of staffing 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 emailed to the Executive Director due to printing issues.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

LIC9099 (FAS) - (06/04)

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