216801868-6-22-2023-21-AS-CFES-CT2VBU-20230622161806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:18:13 PM

Document Has Been Signed on 06/22/2023 04:18 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: 130	DATE:	06/22/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Business Director, Kathy Cushing, Resident Care Director Jordan Choat, and Health Care Coordinator, Robbi Dunham		TIME COMPLETED:	04:30 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 11:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Business Director, Cathy Cushing, Resident Care Director, Jordan Choat, and Health Care Coordinator/RN, Robbi Dunham. Executive Director/Administrator, Angie Boucher-Turin, was available by telephone. Executive Director gave permission for Health Care Coordinator/RN 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 Business Director, Resident Care Director, and Health Care Coordinator/RN: Incident Report 1/Death Report/Death Certificate: CCL received an incident report on 04/20/2023. The report states that on 04/15/2023, Resident 1 (R1) was found on the floor by care staff. R1 was observed to have a large bump on their head and was complaining of pain. Facility contacted Emergency Personnel and R1 was transported to the hospital and was admitted for internal bleeding. Facility made all appropriate notifications per regulation. On 4/20/2023, CCL received a death report for R1. Report states that on 04/18/2023, R1 passed away while at the hospital. Facility requested for R1's Death Certificate and submitted the document to CCL when it was received on 06/19/2023. LPA reviewed reports and facility's fall procedures. Review showed that Facility acted in a timely manner and contacted Emergency Personnel per facility protocol. Incident Report 2: CCL received an incident report on 04/24/2023. The report states that on 04/21/2023, Care staff observed Resident 2 (R2) to be unresponsive. Care Staff contacted Emergency Personnel and R2 was transported to the hospital to be evaluated. Report states that Facility conducted a care conference and reassessed R2's care plan due to R2's changing care needs. Facility made all appropriate notifications per regulation. As of today, 06/22/2023, R2 is on hospice. Facility has continued to communicate with R2, their Responsible Party, and their Physician regarding R2's 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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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: 06/22/2023

NARRATIVE

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Continued from LIC809

Incident Report 3: CCL received an incident report on 04/28/2023. The report states that on 04/24/2023, Care staff observed Resident 3 (R3) on the floor. R3 reported to staff that they fell and had pain in their wrist. Care Staff contacted Emergency Personnel and R3 was transported to the hospital where it was determined that R3 had a broken wrist. Facility made all appropriate notifications per regulation.
As of today, 06/22/2023, R3 is back at the community. R3's has been observed to be at baseline with no complaints of wrist pain.

Incident Report 4: CCL received an incident report on 04/28/2023. The report states that on 04/24/2023, Resident 4 (R4) reported to staff that they had severe pain in their head and neck. Care Staff contacted Emergency Personnel and R4 was transported to the hospital to be evaluated. Facility made all appropriate notifications per regulation.
As of today, 06/22/2023, R4 is back at the community. Per conversation with Executive Director, the hospital did not find anything abnormal with R4 and R4 returned to the facility on the same day. R4 has been observed to be at baseline and to be doing well.

Incident Report 5: CCL received an incident report on 04/28/2023. The report states that on 04/26/2023, Care staff observed Resident 5 (R5) on the floor. R5 was observed to be bleeding from their head and reported to the care staff that they fell. Facility contacted Emergency Personnel and R5 was transported to the hospital and was admitted for observation. Facility made all appropriate notifications per regulation.
As of today, 06/22/2023, R5 is back at the community. Per conversation with Executive Director, R5 was discharged from the hospital and stayed at a Skilled Nursing Facility for a short time. R5 has since been observed to be at baseline and to be doing well.

Incident Report 6: CCL received an incident report on 05/10/2023. The report states that on 05/06/2023, Resident 6 (R6) reported to staff that they had back pain. Care Staff provided R6 with Tylenol and checked on R6 15 minutes later where R6 reported that the Tylenol did not work and their pain had worsened. Care staff contacted Emergency Personnel and R6 was transported to the hospital where it was found that R6 had a spontaneous compression fracture. Facility made all appropriate notifications per regulation.
Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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: 06/22/2023

NARRATIVE

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Continued from LIC809C

As of today, 06/22/2023, R6 is back at the community. Per conversation with Executive Director, the hospital reported that they were unable to determine the cause of fracture. R6 has also been unable to determine the cause of fracture. R6 has been observed to not be in pain and is at baseline.

Incident Report 7: CCL received an incident report on 05/17/2023. The report states that on 05/13/2023, Care staff observed Resident 7 (R7) on the floor. R7 reported to staff that they fell. R7 denied hitting their head and did not any complaints of pain. The report states that later on 05/13/2023, R7 reported to care staff that they had pain from their fall and requested for Tylenol. Care Staff contacted Emergency Personnel and R7 was transported to the hospital where it was determined that R7 had two broken ribs. Facility made all appropriate notifications per regulation.
As of today, 06/22/2023, R7 is back at the community. Per conversation with Executive Director, R7 was discharged from the hospital and stayed at a Skilled Nursing Facility for a short time. Facility has continued to communicate with R7, their Responsible Party, and their Physician regarding R7's care needs.

Incident Report 8/Incident Report 9/SOC341: CCL received two incident reports and an SOC341 report on 05/17/2023. Reports state that on 05/17/2023, Resident 8 (R8) was moving behind Resident 9's (R9) chair during meal time. R9 grabbed R8's shirt to have them sit in their chair. R8 then struck R9 in the neck. Care staff separated and redirected the two residents. R9 was observed to have no injuries or complaints of pain. Facility made all appropriate notifications per regulation.
Per conversation with Executive Director, video cameras were reviewed and it was discovered that R9 bit R8 on the hand when R8 attempted to move past their chair to sit down for their meal. R8 and R9 are both part of the facility's memory care community. Facility has increased staff supervision and have re-arranged their dining room to ensure residents' safety.

Incident Report 10/SOC341: CCL received an incident report and SOC341 Report on 05/23/2023. Reports state that on 05/22/2023, Resident 10 (R10) reported to care staff that they felt their family member was asking for large sums of money. R10 also stated that they felt it was not in a harassing manner. Facility made all appropriate notifications per regulation.

Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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: 06/22/2023

NARRATIVE

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Continued from LIC809C

Per conversation with Executive Director, R10's family member was observed to be aggressive with facility staff in obtaining their requests for money. Facility discussed the situation with R10. As of today, R10's family member has not returned to the building. R10 drafted a letter outlining their visitation wishes. Facility has continued to communicate with R10 and family members regarding visitation.
LPA spoke with R10. Per conversation with R10, LPA was informed that the money they are providing for their family member was their decision and that they were not forced to provide the money. R10 stated to LPA that they have no concerns regarding the incident and they wanted to provide some financial support.

Death Report 11: CCL received an death report on 05/26/2023. Report states that on 05/18/2023, Resident 11 (R11) was seen at the hospital for fluid around their heart and for shortness of breath. Report states that R11 passed away while at the hospital and was not on hospice. Facility made all appropriate notifications per regulation.
LPA is requesting for R11's Death Certificate to be submitted to CCL for review once it has been received by the facility.

LPA conducted a walk through of the facility.

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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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