216801868-11-3-2023-21-AS-KMOA-CXLPA9-20231115100821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 11/03/2023
Date Signed: 11/03/2023 03:25:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230918163333

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: 129	DATE:	11/03/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director/Administrator, Angie Boucher-Turin		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Executive Director/Administrator, Angie Boucher-Turin.

During the course of the Investigation, LPA requested and reviewed documents, conducted interviews and made observations. There is an allegation of Personal Rights where Staff Member confronted a Resident and yelled at them in the facility's dining room. LPA conducted four staff interviews and five resident interviews. Due to conflicting information provided during interviews conducted, the LPA is unable to determine if a Personal Rights violation occurred. 4 of 4 staff members and 4 of 5 residents stated they have never seen a Staff Member yell at a resident or speak to them in a rude or mean manner. Therefore, the allegation of "Personal Rights" is Unsubstantiated.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230918163333

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/03/2023

NARRATIVE

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Continued from LIC9099

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

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: 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

LIC9099 (FAS) - (06/04)

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