216801868-2-17-2023-21-AS-CFES-CP5UU5-20230217145259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 02/17/2023
Date Signed: 02/17/2023 02:53:08 PM

Document Has Been Signed on 02/17/2023 02:53 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: 137	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Administrator, Angie Boucher-Turin		TIME COMPLETED:	03:00 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 10:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Executive Director, Angie Boucher-Turin. The visit is focused on the Infection and Control Practices of this facility. Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a cleaning and disinfecting schedule that occurs twice per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Residents. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders. LPA and Administrator discussed the following: Covid and Influenza A Protocols Staffing Resources and Staff Training Incident/Death Reports and Reporting Requirements Annual Inspection Expectations Facility has a plan in place if a staffing shortage were to occur. Facility has submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL). 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: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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: 02/17/2023

NARRATIVE

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Continued from LIC809

Facility has a Central Pull Fire Alarm system that is directly connected to the Fire Department. Fire extinguishers were last serviced December 2022. Per facility inspection records, smoke detectors and fire alarms were last tested in July 2022. Elevators were last inspected on 3/9/2022. The last facility fire and evacuation drill was conducted in January 2023.

LPA requested the following documents to update facility file:

Administrative Organization (LIC 309)
Affidavit regarding Client/Resident Cash Resources (LIC 400)
Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Surety Bond (LIC 402)
Register of Clients/Residents (LIC 9020)
Updated Liability Insurance
Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by Friday, 3/10/2023.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report 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: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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