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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 05/08/2026
Date Signed: 05/08/2026 10:37:03 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
04/08/2026 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20260408113148
FACILITY NAME:ALMAVIA OF SAN RAFAELFACILITY NUMBER:
216801868
ADMINISTRATOR:TRACY FREUDENDAHLFACILITY TYPE:
740
ADDRESS:515 NORTHGATE DRIVETELEPHONE:
(415) 491-1900
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:160CENSUS: 116DATE:
05/08/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Executive Director, Tracy Freudendahl, Resident Services Director, Elvira Suciu, and Resident Care Director, Isabel SaundersTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Personal Rights
Facility did not provide resident explanation of additional services when initiating a new level of care
INVESTIGATION FINDINGS:
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At approximately 8:30AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to deliver findings for a complaint investigation regarding the above allegations and met with Executive Director, Tracy Freudendahl, Interim Resident Services Director, Elvira Suciu, and Resident Care Director, Isabel Saunders.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Personal Rights, and Facility did not provide resident explanation of additional services when initiating a new level of care.” Complaint alleged that the facility was forcing Resident 1 (R1) to take medications multiple times a day and that R1’s care plan was changed from a Level 2 or 3 when it should be a Level 0. Per report, R1 is independent and does not need additional care or help with their medications. Complaint also stated that R1

Continued on LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20260408113148
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: 05/08/2026
NARRATIVE
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Continued from LIC9099

was being mentally brutalized and psychologically tortured due to being forced to take medication, having facility staff knock on their door three times a day for medications, and being charged $900 per month for care they did not need.

“Personal Rights” – Interview with Resident 1 (R1) stated that it is wrong that facility staff are coming into their room to bother them about medications. Per R1, they have told facility staff that they don’t want medication, but facility staff keep coming to their room and keep pushing them to take medication. R1 stated that after refusing, facility staff leave with the medication.

Review of facility’s policy under “The Six Rights” stated that the seventh right that a resident has is the “Right to Refuse.” Per facility document, residents may refuse medication at any time for any reason, but facility staff should try at least three times. Review of facility documents showed that R1 has been refusing their medications and facility has been notifying their primary care physician of the refusals.

Review of R1’s file indicated that the facility received communication from R1’s Psychiatrist on 03/20/2026. Per communication, the facility has been directed to continue administering R1’s medication per physician orders based on R1’s medical history and to keep R1 on the facility’s medication management program.

“Facility did not provide resident explanation of additional services when initiating a new level of care” – Review of R1’s file showed that they moved to the community on 02/14/2026. Per facility documents, R1’s initial level of care was assessed at a Level 1 on 02/12/2026. R1’s care included being on the facility's medication management program, having showers two times per week, escorts, and reminders. Per facility email correspondence, R1’s level of care would be reassessed after 30 days for accuracy. On 03/10/2026, R1’s level of care was lowered to a Level A and included being on the facility's medication management program. Further review of R1’s Level A care plan showed that R1 signed the document on 03/10/2026, indicating that they were informed of the care changes made. Review of R1’s financial transaction report indicated that from February 2026 to May 2026, R1 has not been charged an additional $900/month.

Based on record review, interviews conducted, and observations made, this allegation is Unfounded. A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. Copy of report discussed and provided to Executive Director, Interim Resident Care Director, and Resident Care Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2