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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 11/03/2023
Date Signed: 11/03/2023 03:27:12 PM


Document Has Been Signed on 11/03/2023 03:27 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 RAFAELFACILITY NUMBER:
216801868
ADMINISTRATOR:ANGELA BOUCHER-TURINFACILITY TYPE:
740
ADDRESS:515 NORTHGATE DRIVETELEPHONE:
(415) 491-1900
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:160CENSUS: DATE:
11/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director/Administrator, Angie Boucher-TurinTIME COMPLETED:
03:45 PM
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At approximately 1:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Angie Boucher-Turin. The purpose of the visit was to follow up a self-reported incident that were submitted to Community Care Licensing (CCL).

Incident Report 1/SOC-341: CCL received an incident report/SOC-341 report on 10/25/2023. Reports state that on 10/23/2023, Resident 1's (R1) Responsible Party informed the Executive Director of a stolen diamond necklace. Facility made all appropriate notifications per regulation.

Per conversation with Executive Director, the facility is currently conducting an extensive internal investigation regarding the missing jewelry and are communicating regularly with the San Rafael Police Department and R1's Responsible Party.

LPA was provided with documentation related to the investigation.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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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