216801868-7-19-2024-21-AS-VBEI-D7HSEY-20240725134932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 07/19/2024
Date Signed: 07/19/2024 10:19:36 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
06/12/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240612092722

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: 112	DATE:	07/19/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator/Executive Director, Angie Boucher-Turin		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff was unaware of resident’s change of condition
Staff are mismanaging resident’s medications

INVESTIGATION FINDINGS:

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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations 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 that Staff were not aware of resident’s change in condition. Per Complainant, Resident 1 (R1) asked to be left outside so they could die. Complainant stated that they notified the facility of the conversation and the facility contacted emergency personnel. Complainant stated that R1 left with emergency personnel to be evaluated and had concerns since R1 no longer had a primary care physician or psychiatrist. Complainant also stated that R1 complained of stomach pain that would not go away and had trouble sleeping. Complainant was unable to state if R1 notified the facility of their stomach pain and of their trouble sleeping. Further discussion with the Complainant stated that they did not have
Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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-20240612092722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 RAFAEL	FACILITY NUMBER: 216801868
	VISIT DATE: 07/19/2024

NARRATIVE

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Continued from LIC9099

concerns with the facility and instead had concerns with other medical entities. Review of facility documents showed that R1 is their own responsible party, is independent of their care needs, and can communicate their needs. Review of Incident Report dated 06/17/2024, stated that R1 notified facility staff that they were having symptoms of shortness of breath, a burning sensation in their stomach, and increased anxiety. Review of Incident Report dated 06/18/2024 stated that facility staff was notified that R1 was having a mental health crisis. Reports showed that for both incidents, facility staff contacted emergency personnel to evaluate R1, and notified all appropriate parties per Title 22 Regulations.

There is an allegation that staff are mismanaging resident’s medications. Complainant alleges that R1 is in distress and does not have access to their medication. Review of R1’s Physician’s Report dated 01/25/2019, and Resident Care Plan dated 01/07/2024, stated that R1 is able to manage and store their own medications. Based on review of documents, interviews conducted, and observations made, these allegations are Unfounded.

A finding that the complaint is UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC9099 (FAS) - (06/04)

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