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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:10:02 PM


Document Has Been Signed on 04/26/2024 03:10 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
SANTA ROSA RO, 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: 117DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator/Executive Director, Angie Boucher-TurinTIME COMPLETED:
03:15 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator/Executive Director, Angie Boucher-Turin. Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 160 residents and an approved fire clearance for 130 non-ambulatory residents, of which 40 residents can be bedridden. Facility has an approved hospice waiver for 20 individuals. Upon arrival, LPA was informed that there were 117 Residents in care and 29 staff members on-site.

At approximately 9:20AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:50AM, LPA conducted a walk-though of the facility with Maintenance Director. LPA observed the following: Facility is a 3 story building for Assisted Living and Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for a sample size of 12 sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected November 2023. Facility's fire and sprinkler system was last inspected December 2023. Facility's last emergency/disaster drill was conducted March 2024.
At approximately 12:00PM, LPA reviewed staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification.

Administrator's Certificate for Angela Boucher-Turin (7001386740) is current with an expiration date of 11/11/2025.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.



No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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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