216801868-3-24-2023-21-AS-CFES-CQ8V2M-20230324160323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:03:33 PM

Document Has Been Signed on 03/24/2023 04:03 PM - 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:	ALMAVIA OF SAN RAFAEL		FACILITY NUMBER:	216801868
ADMINISTRATOR:	ANGELA BOUCHER-TURIN		FACILITY TYPE:	740
ADDRESS:	515 NORTHGATE DRIVE		TELEPHONE:	(415) 491-1900
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	160	CENSUS: 133	DATE:	03/24/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Resident Care Director, Beki Darrow		TIME COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 2:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Resident Care Director, Beki Darrow. Executive Director/Administrator, Angie Boucher-Turin, was available by telephone. Executive Director gave permission for Resident Care Director to sign documents in their place. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). LPA reviewed the following reports with Executive Director/Administrator, and Resident Care Director: Incident Report 1: CCL received an incident report on 03/06/2023. The report states that on 03/02/2023, Resident 1 (R1) was found unresponsive by care staff. Care staff observed R1 to feel clammy, have cool skin, and appeared pale. R1 was taken to the hospital by Emergency Personnel. Facility made all appropriate notifications per regulation. PA discussed R1 with Executive Director and Resident Care Director. As of 03/24/2023, R1 is still undergoing testing to determine the cause of their symptoms. Facility will update R1's care plan appropriately. Incident Report 2: CCL received an incident report on 03/06/2023. The report states that on 03/01/2023, Resident 2 (R2) was observed by their spouse to have drank water with Polident in it. Care Staff notified Poison Control and it was determined that R2 did not have to go to the hospital. Facility made all appropriate notifications per regulation. The report states that Facility conducted a care conference and reassessed R2's care plan. LPA discussed R2 with Executive Director and Resident Care Director. As of 03/24/2023, R2 has been transitioned to Memory Care due to a change in their care needs. Continued on LIC 809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ALMAVIA OF SAN RAFAEL	FACILITY NUMBER: 216801868
	VISIT DATE: 03/24/2023

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Continued from LIC809

Incident Report 3 /SOC-341: CCL received an incident report on 03/17/2023. The report states that on 03/09/2023, Staff Member 1 (S1) reported to Facility Management concerns regarding Staff Member 2 (S2). S1 reported that while responding to Resident 3's (R3) call bell light, R3 asked S1 to stay with them as they did not feel safe. Report also detailed interactions that S1 and S2 had with three other residents of the facility. These residents were not able to be identified by S1. These interactions included the type of care the residents received by S2.
LPA discussed R3 with Executive Director and Resident Care Director. Per conversation with Executive Director/Administrator and Resident Care Director, S1 is an agency staff member and S2 is a facility employee. At this time, the facility has suspended S2 from the facility pending an internal investigation. The facility has also conducted two training in-services and has another one scheduled for 03/30/2023.

LPA was provided with copies of training in-service documentation.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC 811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC809 (FAS) - (06/04)

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