<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801868
Report Date: 02/02/2022
Date Signed: 02/02/2022 10:13:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ALMAVIA OF SAN RAFAELFACILITY NUMBER:
216801868
ADMINISTRATOR:ANGELA BOUCHER-TURINFACILITY TYPE:
740
ADDRESS:515 NORTHGATE DRIVETELEPHONE:
(415) 491-1900
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:160CENSUS: 116DATE:
02/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Administrator, Angela Boucher-TurinTIME COMPLETED:
10:45 AM
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
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Almavia of San Rafael for the purpose of conducting a Case Management-Deficiency inspection. LPA Sarangi met with Administrator, Angela Boucher-Tourin, and was granted access into the facility.

Department learned via a Special Incident Report (SIR) that on 01/01/2022 resident (R1) left the facility unassisted at 12:48 PM and was found by Local Law Enforcement at a nearby gas station at 01:50 PM. Resident physician's report dated for 05/20/2021 states that resident has a diagnosis of dementia and not allowed to leave facility unassisted. (see copies, LIC 809-D) All staff received training regarding residents and elopement. Resident (R1) came back to facility unharmed a few days later due to being in the care of the Responsible Party.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2022
Section Cited

1
2
3
4
5
6
7
87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering. This requirement was not met as evidenced by: Based on record review the facility didn't comply with this section for 1of1 residents which poses an immediate
8
9
10
11
12
13
14
Health, Safety risk to residents in care. Resident R1 isn't allowed to leave facility unassisted; left on 01/01/2022 through the egress doors after an associate left through the same door. Resident was found at the gas station by local law enforcement.
8
9
10
11
12
13
14
Proof of training with participants signature, trainer & date of training already submitted to CCL during Case Management.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2