216801868-9-29-2021-21-AS-HDBI-C7J5EE-20211005195327

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:32:43 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
08/10/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210810115107

FACILITY NAME:	ALMAVIA OF SAN RAFAEL		FACILITY NUMBER:	216801868
ADMINISTRATOR:	ELIZABETH DONOVAN		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 did not follow proper quarantining protocols resulting deaths

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Almavia of San Rafael for the purpose of delivering 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, witnesses and various outside parties, reviewed various documents including resident, staff and facility records.

Complaint alleges that Staff did not follow proper quarantining protocols resulting deaths. Based on LPA’s observation of staff records, facility records and interviews that were conducted with staff and witnesses, LPA learned that there was an outbreak of COVID-19 at the facility in late December 2020 through early January 2021. However, LPA was unable to identify a specific resident or staff not following proper quarantining protocols. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion: 0

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-20210810115107

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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Based on the interviews that were conducted and the documents reviewed, the allegations of, staff did not follow proper quarantining protocols resulting deaths is Unsubstantiated. A finding that the complaint allegation of staff did not follow proper quarantining protocols resulting deaths is unsubstantiated, meaning that although the allegation 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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