216801868-9-29-2021-21-AS-HDBI-C7J53B-20211005193538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:35:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210708154058

FACILITY NAME:	ALMAVIA OF SAN RAFAEL		FACILITY NUMBER:	216801868
ADMINISTRATOR:	JOHN BELTZ		FACILITY TYPE:	740
ADDRESS:	515 NORTHGATE DRIVE		TELEPHONE:	(415) 491-1900
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	160	CENSUS: 107	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Angela Boucher-Turin		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff failed to supervise resident resulting in unexplained injuries
Staff failed to ensure resident is seen by a physician
Staff failed to properly store medication
Facility did not notify authorized representative of incident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced at Almavia of San Rafael to deliver complaint findings. LPA was greeted at the door by Administrator, Angela Boucher-Turin. LPA was granted access into the facility.

During the course of the investigation, LPA interviewed staff members, residents and various outside parties. LPA reviewed various documents including resident records, Program Plan of Operation and an incident report received on July 22, 2021 regarding an incident that occurred on June 29, 2021.

Complaint alleges that Staff failed to supervise resident (R1) resulting in unexplained injuries. Based on interviews conducted R1 and multiple other residents LPA was unable to identify any concerns of neglect or lack of supervision at this time. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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-20210708154058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ALMAVIA OF SAN RAFAEL	FACILITY NUMBER: 216801868
	VISIT DATE: 09/29/2021

NARRATIVE

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Complaint alleges that staff failed to ensure resident is seen by a physician. Based on interviews and record review, LPA learned throughout the investigation that the facility was able to verify that R1 is seen by a Primary Care Physician.

Complaint alleges that staff failed to properly store medication. Based on a review of the Medication Assessment Record (MAR) and Physician Order. LPA learned that this medication order was not missed and that it was properly secured.

Complaint alleges that facility did not notify authorized representative of incident. Based on interviews, LPA learned that the Responsible Party was notified of an incident that occurred at the facility. However, R1, and the Responsible Party cannot determine or articulate how the incident occurred.

Based on the interviews that were conducted, the documents/evidence reviewed, the allegations of, Staff failing to supervise resident resulting in unexplained injuries, staff failing to ensure resident is seen by a physician, staff failing to properly store medication and facility not notifying authorized represented of incident is Unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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