216801868-9-29-2021-21-AS-HDBI-C7J5US-20211005201625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801868
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:38:30 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
06/11/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210611140505

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 does not communicate with resident representative regarding resident's care needs.
Facility is short staffed.
Facility staff did not have resident re-appraised.
Facility does not adhere to Admissions Agreement.
Staff failed to execute emergency disaster plan.
Staff are mismanaging resident's medications.
Facility is not allowing resident to have visitations.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Farhaan Sarangi arrived at Almavia of San Rafael Unannounced 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, additional residents and various outside parties. LPA reviewed various documents such as resident records, facility records, staff roster and visitation records for the past 60 days.

Complaint alleges that Staff does not communicate with resident representative regarding resident's care needs, facility did not have resident reappraised and the facility does not adhere to the Admission Agreement. Based on record reviews and interviews, LPA learned throughout the investigation that the Responsible Party signed for the appropriate Change of Condition to Level 4 during the reappraisal process. (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-20210611140505

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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LPA observed that the level of care was lower during the initial admission and that the Admission Agreement was followed. This was confirmed during a review of resident records and the Admission Agreement.

Complaint alleges that facility is short staffed. Based on record review, LPA learned that the staff Roster appeared to be appropriate at the time of the review. In addition, two subsequent complaint inspection investigations were conducted unannounced on June 16, 2021 and July 16, 2021. LPA observed sufficient amount of staff members present at the facility.

Complaint alleges that staff failed to execute Emergency Disaster Plan. Based on record review, LPA learned throughout the investigation that the last Emergency Disaster drill was conducted on March 16, 2021 along with the Life Safety System Inspection.

Complaint alleges that staff are mismanaging residents’ medication. Based on interviews, LPA learned through a follow-up interview that the Doctor changed the medication which does not have anything to do with the facility mismanaging the residents’ medication.

Complaint alleges that Facility is not allowing resident to have visitations. Based on record review, LPA reviewed the visitation records for the time frame of May to July 2021 and learned that the Responsible Party along with another individual was visiting the resident from late May to Late June 2021. The visitation log was appropriately filled out and signed by individuals entering and departing the facility.

Based on the interviews that were conducted, the observation of the facility and the documents/evidence reviewed, the allegations of, Staff does not communicate with resident representative regarding resident's care needs, facility is short staffed, facility staff did not have resident re-appraised, facility does not adhere to Admissions Agreement, staff failed to execute emergency disaster plan, staff are mismanaging resident's medications, facility is not allowing resident to have visitations will be Unsubstantiated. A finding that the complaint allegations are unsubstantiated, meaning 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, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was signed and given to the Administrator.

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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