216801868-4-2-2021-21-AS-KMOA-BZTRCH-20210406125420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 04/02/2021
Date Signed: 04/02/2021 03:18:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2020 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20201216095847

FACILITY NAME:	ALMAVIA OF SAN RAFAEL		FACILITY NUMBER:	216801868
ADMINISTRATOR:	JOHN BELTZ		FACILITY TYPE:	740
ADDRESS:	515 NORTHGATE DRIVE		TELEPHONE:	(415) 491-1900
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	160	CENSUS: 113	DATE:	04/02/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator, John Beltz		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff handle residents in a rough manner
Facility staff failed to provide adequate food service
Facility staff failed to provide a comfortable temperature for the residents
Facility staff failed to keep the facility clean
Facility is in disrepair
Facility is unsanitary.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi and Licensing Program Manager (LPM), Kimberley Mota made contact on this date, by phone, and conducted an unannounced virtual visit with the Administrator, John Beltz for the purpose of delivering complaint findings and to close the complaint. An in-person complaint investigation inspection could not be done due to COVID-19 precautions.

Beginning on December 21, 2020 at approximately 01:50 PM, Licensing Program Analysts (LPAs), Farhaan Sarangi and Carla Fernandes-Goes investigated the above allegations. During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties. LPA Sarangi and Fernandes-Goes toured the facility on December 21, 2020 during the opening of this complaint. LPA Sarangi also reviewed various documents including facility records, policy and procedures.

(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: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

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-20201216095847

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ALMAVIA OF SAN RAFAEL	FACILITY NUMBER: 216801868
	VISIT DATE: 04/02/2021

NARRATIVE

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Complaint alleges that the facility staff handle residents in a rough manner. Based on interviews LPA Sarangi learned that the complainant was not able to recall any details of the incident including time, date, resident or staff involved. LPA was not able to identify any other witnesses to the alleged incident and was unable to prove or disprove the alleged incident that occurred.

Complaint alleges that the facility staff failed to provide adequate food service. During an interview with complainant LPA learned that complainant alleged that there has been ants and hair in food served and, at times, the portions are too small and are either under or over cooked. Complainant was unable to identify when this occurred, provide any supporting items such as pictures and confirmed that facility will provide second helpings anytime a resident wants more food. Based on multiple interviews with residents, staff and outside parties LPA was unable to identify any other witnesses that have observed ants or hair in food and all felt that the quantity and quality of the food were acceptable. Based on observations, LPA Sarangi and Fernandes-Goes found the food service to be adequate during a facility tour on December 21, 2020. LPA was not able to gather sufficient evidence to prove or disprove the allegation.

Complaint alleges licensee failed to ensure that the common parts of the facility are not maintained at a comfortable temperature, clean and sanitary at all times and repairs were made in a timely manner. Complainant was unable to recall concerns of repairs not being made in a time manner. Based on observations during virtual tours of the facility on December 21, 2020 at 01:50 PM and February 24, 2021 at approximately 12:30 PM LPAs observed the common areas of the facility to be clean and in good repair including but not limited to the kitchen, which was observed to be clean in good condition with food properly stored and bathrooms, which were clean and supplied with paper towels. LPA Sarangi and Fernandes-Goes observed the temperature to be 74 degrees in the dining hall and 75 degree on the first floor bistro which fall within Title 22 regulations. All other common areas were found to be clean and in good repair at the time of the Virtual Tours. Based on interview with multiple residents and outside parties LPAs were unable to identify any other witness that had concerns of the temperature or condition of the property.

Based on the interviews that were conducted, the observation of the facility and the documents/evidence reviewed, the allegations of, Facility staff handle residents in a rough manner, Facility staff failed to provide adequate food service, Facility staff failed to provide a comfortable temperature for the residents, Facility staff failed to keep the facility clean, Facility is in disrepair and Facility is unsanitary is 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 allegations are Unsubstantiated.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

LIC9099 (FAS) - (06/04)

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