216801868-11-22-2024-21-AS-CFES-DB9UFE-20241122143236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 11/22/2024
Date Signed: 11/22/2024 02:32:43 PM

Document Has Been Signed on 11/22/2024 02:32 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 RAFAEL		FACILITY NUMBER:	216801868
ADMINISTRATOR/ DIRECTOR:	ANGELA BOUCHER-TURIN		FACILITY TYPE:	740
ADDRESS:	515 NORTHGATE DRIVE		TELEPHONE:	(415) 491-1900
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 160	TOTAL ENROLLED CHILDREN: 0	CENSUS: 122	DATE:	11/22/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Executive Director/Administrator, Angie Boucher-Turin		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:10AM, 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 self-reported incidents that were submitted to Community Care Licensing (CCL). The Santa Rosa Regional Office (SRRO) received 9 late incident reports from the facility. Review of reports showed that incidents occurred on the following dates: 10/28/2024, 10/29/2024, 10/31/2024, 11/01/2024, and 11/03/2024. Reports were received by the SRRO on 11/12/2024. During LPA's visit, LPA discovered that Staff Member 1 (S1) did not submit the reports timely and that the Executive Director submitted the incident reports. Per Title 22 Regulations, incident reports must be submitted to CCL within seven (7) days of the incident occurring (deficiency cited, LIC809D, Regulation 87211(a)(1)). LPA followed up on the following incidents: Incident Report 1/SOC341: CCL received an incident report and SOC341 on 10/17/2024. Reports state that on 10/17/2024, Resident 1's (R1) family notified facility management of interactions between a facility staff member and Resident 1. Per R1's family, R1 stated to them that Staff Member 2 (S2) kissed them on two separate occasions. Facility made all appropriate notifications per regulation. Incident Report 2/SOC341: CCL received an incident report and SOC341 on 11/13/2024. Reports state that on 11/12/2024, facility management was informed by Staff Member 3 (S3) that they observed Staff Member 4 (S4) pinch Resident 2's (R2) nose and raise a hand towards them. Per report, the incident occurred 2 months prior. Facility made all appropriate notifications per regulation. Incident Report 3: CCL received an incident report on 11/20/2024. Reports state that on 11/18/2024, facility staff notified Executive Director that a former resident's medication was missing. Per report, the missing medications were discovered on 11/18/2024. Facility made all appropriate notifications per regulation. Continued on LIC809C

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Caitlynn Felias	TELEPHONE: 707-588-5039
	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/22/2024

NARRATIVE

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Continued from LIC809

Per discussion with ED, internal investigations are ongoing and they have been in contact with the San Rafael Police Department regarding the incidents.

LPA requested and reviewed documents, and conducted interviews.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Confidential Names (LIC811) Plan of Corrections, and Appeal Rights discussed and provided to 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: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/22/2024 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...below. This requirement was not met as evidenced by: Licensee did
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	Licensee to submit Inservice Training for management and direct care staff. Training to include the following: Date, Topic, Name/Job Role, and Signatures. Training to be submitted tp CCL by POC due date of 12/02/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Caitlynn Felias	TELEPHONE: 707-588-5039
	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC809 (FAS) - (06/04)

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