216801868-9-8-2026-21-AS-VBEI-DXYTNU-20260916145320

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 09/08/2026
Date Signed: 09/08/2026 03:08:48 PM

Unsubstantiated

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
07/29/2026 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20260729084558

FACILITY NAME:	ALMAVIA OF SAN RAFAEL		FACILITY NUMBER:	216801868
ADMINISTRATOR:	TRACY FREUDENDAHL		FACILITY TYPE:	740
ADDRESS:	515 NORTHGATE DRIVE		TELEPHONE:	(415) 491-1900
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	160	CENSUS: 129	DATE:	09/08/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director, Tracy Freudendahl		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Unqualified staff providing care to residents
Staff did not serve food in a healthful manner

INVESTIGATION FINDINGS:

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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegations and met with Executive Director, Tracy Freudendahl.

During the course of the investigation, the Department reviewed documents, conducted interviews, and made observations. The following allegations were investigated, "Unqualified staff providing care to residents and Staff did not serve food in a healthful manner." Complaint alleged that a child (C1), approximately 8 or 9 years old, had been providing care to residents. Per report, the child had been taking resident meal orders and delivering food to the residents. Report also stated that the meals have not been served in a healthful manner because the child is not changing gloves after they clean the tables. Report also stated that the child worked in the kitchen and also cleaned facility closets.

Review of C1's file showed that they were 13 years old and had received training at the facility on 07/22/2026
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026

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-20260729084558

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: 09/08/2026

NARRATIVE

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Continued from LIC9099

C1's documentation also showed that they volunteered at the facility from 07/22/2026-07/31/2026, and had the proper documents required for volunteers.

Interview conducted with Executive Director (ED) stated that C1 did the following tasks: cleaned facility storage closets, served and delivered food to residents, cleaned tables, and helped with landscaping at the front of the facility. Per ED, C1 was supervised at all times when they were at the facility and was supervised by the Executive Director, the Business Office Manager (BOM), the Maintenance Director, the Head Chef, and the dining room servers.

Interview conducted with the Resident Care Director (RCD) stated that they observed C1 to be supervised by the Head Chef and the BOM. RCD stated that they did not observe C1 serving meals and was unable to state if C1 was changing their gloves appropriately.

Interview conducted with the Assistant Food Service Director, stated that C1 worked primarily in the dining room to help bus and clean tables, and deliver meals to the residents. Assistant Food Service Director stated that they observed C1 to change their gloves appropriately.

Interview conducted with the Head Chef stated that C1 helped with the following tasks: organize facility storage, how to date produce and facility deliveries, helped serve meals in the dining room, and helped plate desserts. Per interview, C1 was interested in how to become a server, and would shadow and observe the dining room servers. This interview stated that the Head Chef provided safety training to C1 which included training on gloves. Interview also revealed that C1 would occasionally take residents' meal orders while in the dining room, and a dining room server would be there to supervise. Per Head Chef, they observed C1 to change out their gloves appropriately per the training that was provided.

Review of Title 22 Regulations showed that there is no regulation that prohibits an individual under the age of 18 to volunteer at a licensed Residential Care Facility for the Elderly (RCFE). Per Title 22 regulations, 87411(j), volunteers may be utilized and shall be supervised.

Continued on LIC9099C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260729084558

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: 09/08/2026

NARRATIVE

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Continued from LIC9099C

Based on record review, interviews conducted, and observations made, the allegations of, "Unqualified staff providing care to residents," and "Staff did not serve food in a healthful manner," are Unsubstantiated.

A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

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

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026

LIC9099 (FAS) - (06/04)

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