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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:30:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 RAFAELFACILITY NUMBER:
216801868
ADMINISTRATOR:ANGELA BOUCHER-TURINFACILITY TYPE:
740
ADDRESS:515 NORTHGATE DRIVETELEPHONE:
(415) 491-1900
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:160CENSUS: 107DATE:
09/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Angela Boucher-TurinTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Farhaan Sarangi conducted an unannounced case management visit to cite additional deficiencies discovered during a complaint investigation. LPA was greeted at the door by Administrator, Angela Boucher-Turin. LPA was granted access into the facility.

During the complaint investigation dated for July 08, 2021, LPA learned that the facility did not submit an Unusual Incident Report (LIC 624) to Community Care Licensing. In addition, facility missed a Urinalysis lab appointment for R1. (See LIC 809D)

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 of rights provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2021
Section Cited

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
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This requirement was not met as evidenced by:

Based on an email conversation dated for July 23, 2021, it was disclosed that facility missed a Urinalysis order for R1 in May 2021. This poses an immediate health, safety or personal rights risk to persons in care.
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Plan of training and plan of future compliance shall be furnished to the Department of Social Services-Community Care Licensing Division to the Rohnert Park CCL office by POC date of September 30, 2021. Proof of training including sign-in sheet to be submitted to Rohnert Park CCL office by October 12, 2021.
Type B
10/06/2021
Section Cited

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87211 Reporting Requirements:

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.

(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

(C) The use of an Automated External Defibrillator.

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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This requirement was not met evidenced by:

Based on interviews with facility staff, and research of incident reports submitted for Almavia of San Rafael to CCL, did not properly report an incident to the CCL as required by Title 22 regulation. This poses a potential health, safety or personal rights risk to persons in care.
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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: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2021
LIC809 (FAS) - (06/04)
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